Testing the effect of this 4-F program in a real-world intervention, we conducted an exploratory study among 24 outpatients suffering from moderate to severe psychiatric disorders who completed the eight-week intervention. Our main findings were the significant improvement in muscular endurance, as well as coordination, and the increase in the general mental well-being of these patients from baseline to T1, while the depression scores slightly decreased following the 8-week program. Meanwhile, we observed no significant decrease in weight, BMI or body composition. However, we noticed that only the subgroup of patients suffering from psychosis had a slight decrease in abdominal circumference (AC). Finally, we observed a slight change in eating behaviour with a tendency of a decrease in the TFEQ hunger scores over time.
Indeed, we found that patients who completed the 8-week program improved muscular endurance and their coordination with no change in flexibility or whole-body balance. Compared to a previous report in 2012 [43], the Eurofit test battery was used to evaluate physical fitness parameters in patients with schizophrenia or schizoaffective disorder. Both patient groups had impaired limb movement speed, strength and abdominal muscular endurance compared to the healthy controls. This demonstrates that patients with psychiatric illnesses have poor physical performance exacerbated by unhealthy lifestyle habits, feeding and sedentary behaviour; in addition, an increasing duration of illness could be a strong correlate for the performance on several Eurofit test items. Possible reasons for the association of worse physical fitness with a longer duration of illness include the cumulative long-term effect of poor health behaviours such as physical inactivity in patients often suffering from psychomotor slowing. Moreover, the Eurofit test can be recommended for evaluating the physical fitness of inpatients with bipolar disorder. These authors reported that significant correlations with Eurofit test items were found with age, illness duration, body mass index, smoking behaviour, mean daily lithium dosage, plus depressive and lifetime hypomanic symptoms [44].
In the 4-F program, we deliberately chose a good exercise dosage, an 8-week group-based intervention following OMS and the American College of Sports Medicine (ACSM) recommendations [45, 46], using 2 sessions per week of 60 minutes each, sessions with progressive, moderate-intensity aerobic exercises and sessions with ball team sports. Indeed, we observed in the recent literature that these exercise groups varied in duration from 2 to 52 weeks [29, 47], with a mean of 12 weeks, in session duration of 10 to 90 minutes with a mean of 60 minutes [48, 49], frequency of 1 to 4 times/week; [48, 50], the quality and the intensity of physical exercise, performed at a low (yoga or similar), moderate, [51] and moderate to vigorous intensity (aerobic training) (Rahman, 2018) [52]. We found that despite some discrepancies in methodological design, these interventions had a real impact on the physical and mental health of patients suffering from serious psychiatric disorders. We are convinced that the high dropout rates and lack of motivation are obstacles to increasing the retention of patients, and it is crucial to manage their motivation tapering with behavioural and motivational counselling [53].
We also observed an improvement in the general mental well-being of our patients from baseline to postintervention and a slight positive change in depression scores in the 8-week program, while we note no difference in positive or negative scores on the PANSS. In line with a previous work, with 12 weeks of moderate to intense aerobic PA duration, the authors observed enhanced cardiorespiratory fitness, wellbeing and decreased psychiatric symptoms [54]. In a longer 12-week randomised controlled study with PA intervention on first-episode psychotic patients, the authors reported a decrease in positive symptoms on PANSS and psychopathology in general, while exercise was helpful against the negative score increase observed in the control group [55].
This is consistent with a randomised control study reporting better weight management in the intervention group (behavioural interventions, nutrition, and exercise) for drug-naïve first-episode psychotic patients in the first three months following the introduction of atypical antipsychotic drugs compared to control condition groups [56].
Not surprisingly, we found that among our final sample, 79.2% were overweight or obese, and the prevalence of MetS was 37.5%. In the general population, these constellation risk factors have been associated with the development of cardiovascular disease [57]. This result is consistent with the results of a previous meta-analysis [58] which found that almost one in three unselected patients with schizophrenia met the criteria for MetS as well as in a study among bipolar and unipolar depressed patients [59] who demonstrated a higher MetS prevalence and BMI (BD = 46.9% vs. MDD = 35.1%, vs. general population = 22.1%) than the general population. A recent meta-analysis showed that the prevalence of MetS was 31.8% in 18-year-old subjects with depression [60]. In contrast with a previous work, we conducted in 2009, where we found that in a cohort of 153 psychotic patients, 46.4% were overweight or obese, while only 19% of them had MetS [19]. These results indicate that before inciting individuals with psychiatric disorders and who are overweight to increase their level of PA, it is essential to quantify their physical health and low PA level, plus help them establish realistic and gradually attainable objectives in terms of the frequency, intensity and duration of the exercises [61]. The American College of Sports Medicine (ACSM) defined the beneficial exercise dosage, using the frequency, intensity, time and type of exercise as determinants of dosage [45].
Interestingly, we observed no significant decrease in weight, BMI, WC or body composition. This could be due to the short duration of the program, lower participation rate and characteristics of the population studied (most of them were overweight or obese with several diagnoses).
In contrast, in an 18-month controlled study, the active group with a weight control program that included an educational activity significantly reduced their bodyweight and WC [62]. Playing in team sports requires anticipation and speed to understand the actions of team members [22]. Consistent with a 12-week randomised controlled study of PA intervention in psychotic patients, the authors reported no change in BMI [53]. In addition to a previous report [25] in a patient within a first episode of psychosis who followed a 14-week aerobic interval training program, improved metabolic outcomes and cardiorespiratory fitness, the clinical statute remained moderately to severely symptomatic and functionally impaired after the intervention. Meanwhile, we observed that the depression scores slightly decreased in the 8-week program. A large number of clinical studies have investigated PA programs in mood disorders and suggested that exercise can relieve both depressive and anxiety disorders [62].
However, in this exploratory study, we noticed that only the subgroup of patients suffering from psychosis had a slight decrease in abdominal circumference (AC) after 8 weeks of the program. These results were confirmed in a fourteen-week aerobic interval training (AIT) program with 25 individuals after their first psychotic episode. The authors observed the effectiveness of aerobic training in reducing weight and waist circumference by improving maximal oxygen uptake (Abdel-Baki et al., 2013) [25]. In an AIT 14-week study, greater WC reduction and weight loss were reported, while it took 12 to 18 months and 3 to 6 months, respectively, in a previous study to obtain the same magnitude of reduction in WC and weight [63].
This suggests that AIT might induce faster WC reduction than traditional exercise training in a psychiatric population, as demonstrated in the general population [54]; however, we should take into account psychiatric population characteristics such as amotivation or psychomotor slowing to implement a progressive intensity dosage.
We did not observe an improvement in the patient’s VO2 max at the end of the program, while in a 14-week aerobic interval training (AIT), the authors reported a significant increase in VO2 max [25]. This result was confirmed in metabolic syndrome patients; VO2 max increased more after AIT vs. moderate continuous training after 16 weeks and was associated with the removal of more risk factors that constitute metabolic syndrome [54]. In a 4-week randomised, single-blinded controlled clinical trial in 57 patients with depression plus add-on aerobic exercise or no activity, the authors reported that VO2 max and O2 pulse parameters increased over time only in the exercise group and remained unchanged in the control group [64].
In this 8-week intervention, there was no significant improvement in laboratory parameters (lipid profile or fasting glucose) over time, as in a previous controlled study in an exercise and dietetic program conducted in young patients with first-episode psychosis [24]. Since the onset of the disease represents a critical period to prevent side effects and metabolic morbidities, it is crucial to implement effective lifestyle habits and acquire life skills through multidisciplinary trainings and include them in their routine care (as quickly as possible from the onset of the disease) from the initiation of treatment in young patients with serious mental diseases [24]. This result must consider that most of the patients had at least one psychotropic treatment (87.5%; 54.2% benefited from an antipsychotic treatment), which differs from prior reports that observed blood lipid or glucose dysregulations when patients were under atypical AP [65].
Interestingly, we observed a slight decrease in the TFEQ hunger score from baseline to postintervention at T1, in line with previous works that reported that the TFEQ disinhibition and hunger scores increased according to body mass index [19]. PA may represent a valuable factor and predictor to help change the physiological imbalances caused by several psychiatric disorders and unhealthy lifestyles (such as eating attitudes) [66]. Moreover, there is evidence that exercise could influence the drive to eat through the modulation of appetite [67].
Finally, we observed that the effects of the 4-F program’s clinical global impression (gravity and improvement) did not differ 4 weeks postintervention. In line with improvements in the Calgary Depression Scale (CDS) in both the yoga and aerobic exercise groups at 3 months of intervention, it remained stable at the 18-month follow-up in both intervention groups [68].
Limitations
The outcome of this exploratory study is that we demonstrated the feasibility and effectiveness of the 4-F program in young patients with moderate to severe psychiatric disorders in assessing 8-week adapted PA levels and improvement in muscular endurance, as well as coordination and the increase in the general mental well-being. However, there are some limitations to this exploratory study. The first limitation was its nonrandomised controlled nature and lack of an active control group. Nevertheless, we evaluated the effect of a specific 8-week program on mental and physical outcomes in outpatients with a 4-week follow-up period. Second, longitudinal analyses were performed in a relatively small sample size of participants, which suggests that our results and conclusion should be viewed as preliminary. Our dropout rate reached the upper limit of the range reported by previous findings (20 to 50% in outpatients), [41], caused by multiple factors such as the lack of motivation and attrition induced by mental disease itself, the outpatient inclusion, the COVID-19 outbreak with the quarantine periods, the lack of encouragement and priority given to physical activity by psychiatrist and other barriers to engage in exercise program such as psychological difficulties regarding ongoing motivation and the organisation of daily routines [69]. Lastly, the response to physical activity was highly individualized, making it difficult to satisfy everyone However, creative ways and optimised motivation are needed to monitor and enhance adhesion and compliance of this population [70].
Third, the patients’ clinical backgrounds were heterogeneous, and we chose to investigate the effect of a program group including patients with different psychiatric disorders. Nevertheless, these results suggest that an innovative program is feasible and can be effective with improving muscular endurance, as well as coordination and increasing wellbeing over time. Second, we conducted this exploratory study from the perspective of pragmatic and real-world settings to be more inclusive (diagnosis), to initiate exercise, to improve physical health and good lifestyle habits and to prevent weight gain and metabolic dysfunctions.