【医脉通】2018+EPA指南：体力活动作为严重精神疾病的一种治疗方法（ 英文版）.pdf

Original articleEPA guidance on physical activity as a treatment for severe mentalillness:a meta-review of the evidence and Position Statement from theEuropean Psychiatric Association(EPA),supported by the InternationalOrganization of Physical Therapists in Mental Health(IOPTMH)Brendon Stubbsa,b,*,Davy Vancampfortc,Mats Hallgrend,Joseph Firthe,f,Nicola Veroneseg,Marco Solmih,Serge Brandi,j,k,Joachim Cordesl,Berend Malchowm,Markus Gerberj,Andrea Schmittm,n,Christoph U.Corrello,p,q,Marc De Hertr,Fiona Gaughrana,b,Frank Schneiders,Florence Kinnafickt,Peter Falkaim,Hans-Jrgen Mllerm,Kai G.KahluaSouth London and Maudsley NHS Foundation Trust,Denmark Hill,London,SE5 8AZ,United KingdombInstitute of Psychiatry,Psychology and Neuroscience(IoPPN),Kings College London,London,United KingdomcUniversity Psychiatric Centre,Department of Neurosciences and Department of Rehabilitation Sciences,Katholieke Universiteit Leuven,Kortenberg,3070,BelgiumdDepartment of Public Health Sciences,Karolinska Institutet,Solna,171 77,SwedeneNICM Health Research Institute,Western Sydney University,Sydney,AustraliafCentre for Youth Mental Health,University of Melbourne,Melbourne,AustraliagNational Research Council,Neuroscience Institute,Aging Branch,Via Giustiniani 2,35128,Padova,ItalyhDepartment of Neurosciences,University of Padova,Padova,Italy and Padova Neuroscience Center,University of Padua,Padua,ItalyiUniversity of Basel,Psychiatric Clinics(UPK)Center for Affective,Stress and Sleep Disorders,CH-4002,Basel,SwitzerlandjUniversity of Basel,Department of Sport,Exercise,and Health,Division of Sport and Psychosocial Health,CH-4052,Basel,SwitzerlandkKermanshah University of Medical Sciences,Substance Abuse Prevention Research Center and Sleep Disorders Research Center,Kermanshah,IranlDepartment of Psychiatry and Psychotherapy,Heinrich-Heine Universitt Dsseldorf,GermanymDepartment of Psychiatry and Psychotherapy,Ludwig Maximilian University Munich,Nussbaumstrasse 7,80336,Munich,GermanynLaboratory of Neuroscience(LIM27),Institute of Psychiatry,University of Sao Paulo,Rua Dr.Ovidio Pires de Campos 785,05453-010,So Paulo,SP,BraziloHofstra Northwell School of Medicine Hempstead,New York,USApThe Zucker Hillside Hospital,Department of Psychiatry,New York,USAqCharit Universittsmedizin,Department of Child and Adolescent Psychiatry,Berlin,GermanyrUniversitair Psychiatrisch Centrum KU Leuven,3070,Kortenberg,BelgiumsDepartment of Psychiatry,Psychotherapy and Psychosomatic,University of Aachen(RWTH),GermanytSchool of Sport,Exercise and Health Sciences,National Centre for Sport and Exercise Medicine,Loughborough University,Loughborough,Leicestershire,LE11 3TU,UKuDepartment of Psychiatry,Social Psychiatry and Psychotherapy,Hannover Medical School,GermanyA R T I C L E I N F OArticle history:Received 30 May 2018Received in revised form 17 July 2018Accepted 18 July 2018Keywords:Physical activitySedentary behaviourExercisePsychosisSchizophreniaSevere mental illnessBipolar disordersMajor depressive disordersA B S T R A C TPhysical activity(PA)may be therapeutic for people with severe mental illness(SMI)who generallyhave 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,includingschizophrenia-spectrum disorders,major depressive disorder(MDD)and bipolar disorder.Wesearched 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,gradingthe quality of evidence,and identifying gaps,future research needs and clinical practicerecommendations.For MDD,consistent evidence indicated that PA can improve depressive symptomsversus control conditions,with effects comparable to those of antidepressants and psychotherapy.PAcan also improve cardiorespiratory fitness and quality of life in people with MDD,although the impacton physical health outcomes was limited.There were no differences in adverse events versus controlconditions.For MDD,larger effect sizes were seen when PA was delivered at moderate-vigorousintensity and supervised by an exercise specialist.For schizophrenia-spectrum disorders,evidenceindicates that aerobic PA can reduce psychiatric symptoms,improves cognition and various*Corresponding author at:Physiotherapy Department,South London and Maudsley NHS Foundation Trust,Denmark Hill,London,United Kingdom.E-mail address:brendon.stubbskcl.ac.uk(B.Stubbs).http:/dx.doi.org/10.1016/j.eurpsy.2018.07.0040924-9338/2018 Elsevier Masson SAS.All rights reserved.European Psychiatry 54(2018)124144Contents lists available at ScienceDirectEuropean Psychiatryjournal homepage:htt p:/www.europsy-journa subdomains,cardiorespiratory fitness,whilst evidence for the impact on anthropometric measures wasinconsistent.There was a paucity of studies investigating PA in bipolar disorder,precluding anydefinitive recommendations.No cost effectiveness analyses in any SMI condition were identified.Wemake multiple recommendations to fill existing research gaps and increase the use of PA in routineclinical care aimed at improving psychiatric and medical outcomes.2018 Elsevier Masson SAS.All rights reserved.1.Introduction1.1.Serious mental illness,physical co-morbidity and prematuremortalitySevere mental illnesses(SMI),defined as schizophrenia-spectrum disorders,bipolar disorder(BD)and major depressivedisorder(MDD),are leading causes of years lived with globaldisability and are of considerable public health importance 1.Inaddition to the impact of the mental health symptoms and reduceddaily life functioning,people with SMI are at increased risk ofpremature mortality by between 1020 years compared to age-and sex-matched controls 25.While suicide accounts for aconcerning portion of the early mortality 6,7,there is increasingrecognition that physical disorders account for approximately 70%of these premature deaths 3,8.Of notable concern,cardiovascularand metabolic diseases appear to greatly increase the risk of earlydeath in those with SMI 9,which is of particular importance,given the high prevalence of these diseases in SMI 911.Peoplewith SMI are also at increased risk of various other physicalcomorbidities,such as respiratory disease 12,13,poor bonehealth 14 and physical multimorbidity 15.Moreover,peoplewith SMI typically experience pronounced cognitive impairment,which often worsens over time 1618 and for which treatmentapproaches remain limited 19,20.Current treatment for mental health symptoms and func-tioning largely revolves around psychotropic medication 21,22and/or psychotherapeutic interventions 2325.Whilst both ofthese dominant approaches,alone and in combination,havedemonstrated treatment efficacy on mental health symptoms26,their impact on the rising physical health burden in thispopulation is limited,and psychotropic medication may evenhave an adverse relationship with cardiometabolic/physicalhealth 8,9.In addition,antipsychotic medication has beenassociated with reduced grey matter volume in people withschizophrenia 27 while psychotherapeutic interventionsappear to have limited efficacy for cognitive impairment inthis population 28.1.2.Established benefits of physical activity in the general populationIn the general population,there is evidence that physicalactivity is equally effective as frontline pharmacological inter-ventions,such as statins and beta-blockers,in preventingcardiovascular disease mortality 29.Moreover,there is consistentevidence that physical activity and exercise can decrease the risk ofdeveloping cardiovascular and metabolic disease 3032 andreduce inflammatory parameters,such as C-reactive protein33,34,which are commonly raised in people with SMI 35.Conversely,higher levels of sedentary behaviour(characterized byan energy expenditure?1.5 metabolic equivalents(METs),while ina sitting,reclining or lying posture during waking hours 36)areindependently associated with an increased risk of diabetes,cardiovascular disease and premature mortality 37.In thegeneral population,there is also evidence that lower levels ofcardiorespiratory fitness are a more accurate determinant ofpremature death than body mass index(BMI)38.Moreover,thereis evidence that aerobic exercise is effective in improving cognitivefunction in the general population 3943 including potentiallyincreasing hippocampal volume 44.In addition,a recent globalmeta-analysis has demonstrated that higher levels of PA confersprotection from the development of depressive symptoms andMDD 45.1.3.Low levels of physical activity and fitnessDespite the aforementioned,there is evidence to suggest thatless than half of people with SMI(schizophrenia 46,bipolardisorder 47 and major depression 48 49)meet recom-mended physical activity levels of 150 min of moderate-vigorousphysical activity per week 50.Moreover,each of thesepopulations engage in remarkably high levels of sedentarybehaviour 46 48 and have low levels of cardiorespiratoryfitness 51.People with SMI experience,a number of barriersfrom engaging in physical activity exist,such as side effects ofmedications,complications from obesity/poor physical health52,53,lack of resources/professional support 54,variousmotivational factors 55,which calls for targeted interventionsin this highly sedentary population 5658.2.AimsThe overall aims of this meta-review and position statementwere as follows:First,to establish the benefits of physicalactivity/exercise across all categories of severe mental illness(SMI),using top-tier evidence from published systematicreviews and meta-analyses.Second,examine how the benefitsof physical activity may differ across specific SMIs,includingschizophrenia-spectrum disorders,BD and MDD.Finally,to usethese findings to provide guidance for clinical practice,policyand future research.3.Methods3.1.Guidance development processThis guidance paper was performed in accordance with thePRISMA guidelines 59 following a pre-determined,publishedprotocol(PROSPERO registration CRD42017068292).Moreover,thecurrent guidance was conducted in accordance with the EuropeanPsychiatric Association(EPA)guidelines framework and whereverpossible,adopted guidance based on the findings from systematicreviews and meta-analyses 60.3.2.Searches and study selectionTwo independent authors searched from inception to 15thJanuary 2018 Medline/Pubmed,PsychInfo,EMBASE and theCochrane database for systematic reviews(with and withoutmeta-analyses)of studies investigating physical activity/exerciseamong people with SMI,schizophrenia-spectrum disorders,BD orMDD.The search terms included(exercise or aerobic exercise orphysical activity or resistance training)and(schizophrenia orB.Stubbs et al./European Psychiatry 54(2018)124144 125 psychosis or psychotic or major depression or depression orbipolar disorder or serious mental illness or serious mentaldisorder).The reference lists of included articles were also hand-searched.3.3.Type of studies eligible for inclusionWe followed the European Psychiatric Association manual foridentifying and conducting this review and evidence was consid-ered in a hierarchical approach,going from systematic reviews tothe highest level of meta-analyses.In the absence of these two datasources for particular outcomes,we sought to identify newerrandomised/controlled trials.The specific inclusion criteria were:1)systematic reviews(withor without meta-analyses)that synthesised randomised,controlledclinicaltrialsorrandomisedcontroltrials(RCTs)orcontrolledclinicaltrials(CCTs);2)physical activity/exercise interventions,includingaerobic,high intensity and resistance exercise as monotherapy or inconjunction with other treatment options,including psychotropicmedication or psychological therapies;3)systematic reviews of PA,which included people with pooled SMI or schizophrenia-spectrumdisorders,BD or MDD,confirmed through validated assessmentmeasures(e.g.Diagnostic and Statistical Manual of Mental Disorders61(DSM),International Classification of Diseases 62(ICD)criteria),in any setting;4)systematic reviews,which included anon-active/non-exercise control group(e.g.,does not includephysical activity).We excluded mind-body physical activityinterventions,such as yoga and tai-chi,since these activities arepresumed to exert beneficial effects on mental health throughadditional factors distinct from the physical activity itself.3.4.Definition of exercise and physical activityWe included systematic reviews investigating the benefits ofexercise or physical activity in people with SMI.Exercise wasdefined as“planned,structured,and repetitive and has as a final or anintermediate objective the improvement or maintenance of physicalfitness.”63.Within this definition,we included aerobic exercise,high intensity exercise,resistance exercise and mixed exercise(i.e.,aerobic and resistance exercise).Physical activity was defined as“any bodily movement produced by skeletal muscles that results inenergy expenditure”63.We considered exercise/physical activitystudies used as monotherapy or in combination with other types oftreatment,e.g.,psychotropic medication or psychological inter-ventions.3.5.OutcomesAs indicated in the EPA guidelines manual 60,as a first choicein the hierarchy of evidence,we drew evidence from systematicreviews of exercise/physical activity interventions,includingmeta-analyses and/or RCTs/CCTs that considered the outcomeslisted below.In accordance with our published protocol,weincluded data from the largest and/or most recent paperinvestigating each type of PA and each outcome in any population.3.5.1.Primary outcomesThe primary outcomes focused on changes in the severity ofsymptoms,which characterise the included psychiatric disorders.For example,positive and negative symptoms in people withschizophrenia-spectrum disorders;and depressive symptoms inpeople with MDD or BD.3.5.2.Secondary outcomesWe were interested in a range of secondary outcomes,including:?Physical health factors,e.g.,cardiovascular or metabolic param-eter changes,anthropometric measures(e.g.,BMI,waistcircumference)or body composition measures(e.g.,amount ofintra-abdominal and cardiac adipose tissue).?Cardiorespiratory fitness(expressed as percentage maximal orpeak oxygen uptake),muscular fitness.?Increasing physical activity levels or decreasing sedentarybehaviour.?Biomarkers,e.g.,HbA1C,C-reactive protein,brain derivedneurotrophic factor(BDNF),interleukin-6.?Cognitive functioning,e.g.performance in neuropsychologicaltests?Brain structure and connectivity,e.g.,determined throughmagnetic resonance imaging or diffusor tension imagingchanges.?Quality of life and functioning.?Dropout rates and predictors from physical activity interven-tions.?Adverse events(e.g.,injuries sustained from PA)?Economic evaluations.3.6.Data extractionData extraction was conducted by two authors and reviewed bya third author.We extracted data from systematic reviews andmeta-analyses of RCTs/CCTs in