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Health professionals accept exercise as an important contributor to weight control and health maintenance for most medical disorders (1–3). Yet, surprisingly, schizophrenia research has ignored the role of exercise as a legitimate adjunctive treatment for schizophrenia. A Medline search revealed few studies that examine exercise among schizophrenia patients. One study by Greenberg and others engaged subjects in stepped weight-control interventions (4). The studied strategies included exercise, diet, and behavioural modification, as well as treatment with sibutramine, orlistat, vertical banded gastroplasty, and Roux-en-Y surgical procedures. This study reported some success with stepped approaches but did not differentiate the benefits of exercise from other strategies. In summary, we need studies that focus on exercise interventions, especially because we know antipsychotic medications cause weight gain (5–7). Wirshing and others compared weight gain liabilities among men with schizophrenia receiving 5 different drug treatments: clozapine, olanzapine, risperidone, haloperidol, and sertindole (8). They found that olanzapine and clozapine caused the most weight gain. Over 30% of individuals who were treated with olanzapine gained more than 10% of their original weight (9). Increased body weight and obesity are major causes of many chronic diseases, such as hypertension, cardiovascular disease, and diabetes mellitus (10,8). Substantial weight gain may adversely affect self-esteem, social functioning, and physical activity (9). Antipsychotic-induced weight gain is a common cause of noncompliance and discontinuance of treatment, resulting in the return of psychotic symptoms (11). Novel antipsychotic medications commonly cause elevated cholesterol, triglycerides, and blood sugars (12). The health risks from antipsychotic-induced weight gain pose many challenges for psychiatrists, who must weigh the risks and benefits of novel antipsychotic medications. These issues concern patients, their families, and their clinicians. Unfortunately, clinicians lack a body of literature to draw from to help prevent weight gain. To protect against weight gain, health professionals often suggest that patients obtain memberships at local fitness facilities. We decided to study the feasibility of this approach. Purpose of StudyThis small pilot study explored whether patients with schizophrenia would exercise if given access to a local Young Men’s Christian Association (YMCA). To what extent would schizophrenia patients adhere to an exercise program if offered access to a fitness facility? Study DesignThis is a prospective, nonblind pilot study of outpatients with a psychotic disorder who were treated with olanzapine. Ethics approval was obtained, and all participants provided informed consent prior to entering the study. Patients were recruited from the Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Hospital site, in Hamilton, Ontario, or from the Hamilton Program for Schizophrenia. Patients were excluded if they had comorbid illness for eating disorder, substance abuse and (or) dependence, or bipolar disorder. Eligible participants met the following criteria: DSM-IV criteria for schizophrenia or schizoaffective disorder, between age 16 and 55 years, on a stable dose of olanzapine for at least 4 weeks, and stable in the clinical judgment of the principal investigator. A total of 50 subjects were approached to enter the study. Of the subjects, 20 were randomized, and 10 received YMCA passes based on the random allocation. The treating physician determined the dosage of olanzapine used, based on clinical judgment. The study period lasted 6 months. The intervention included a free membership to the YMCA for 6 months. This group met with a YMCA physical activity coach who conducted a fitness assessment of their cardio- vascular endurance and musculoskeletal strength to prescribe an appropriate exercise program. The YMCA physical activity assessment comprised muscular strength tests, push-ups, sit-ups, flexibility, heart-rate monitoring, and 3 walking tests of 6 minutes each. The exercise facility offered a pool, aerobics classes, a weight room, a treadmill, racquetball, a tennis court, a track, and a basketball court. All subjects received information about diet, exercise, and health. To improve access, researchers provided parking vouchers and bus tickets. The research nurse collected data at baseline and endpoint (6 months plus or minus 2 months). The information that was collected included weight, body mass index (BMI), adherence to exercise program, and reasons and date of every withdrawal from the study for YMCA subjects. The nurse also reviewed Canada’s exercise and food guide with all subjects. Table 1 contains the full demographic information that was available for the 10 subjects.
ResultsSubjects
Attendance Figure 1 YMCA subjects (number of sesions monthly) Dropout rates for attendance at the YMCA were 90% at 6 months, 70% at 5 months, and 40% at 4 months. The main reason that the subjects gave for poor attendance was lack of motivation (Table 3).
Weight DiscussionMethodological problems with this study included a small sample size, no blinding for the subjects, and lack of a control sample. A more scientifically rigorous study is necessary to determine whether we can attribute weight loss to regular exercise. Nevertheless, the poor YMCA attendance provides us with valuable clues about barriers to exercise in this population. Most subjects dropped out of the exercise program, despite access to the YMCA. The main reason that was given was a lack of motivation. In the general population, dropout rates for exercise range from 20% to 80% (13). Thus, we should expect that a population with psychosis, dealing with challenges that are not faced by the general population, might have worse rates. One subject who exercised regularly at the YMCA lost 15 kg. Thus, the results suggest that there is a potential for exercise to induce weight loss among this population. The weight increases suggest that clinicians should monitor diet, exercise, and weight gain in patients treated with olanzapine and other antipsychotic medications. It is imperative that research develop effective interventions to help our patients include exercise while taking these medications. In future studies, researchers should consider strategies to increase motivation for exercise. These strategies might include groups, personal trainers, rewards, or a buddy system. Future research should consider the role of treating the negative syndrome to enhance motivation for physical activity. The Stages of Change Model or the Transtheoretical Model (14) may help identify patients who may be ready to adopt regular exercise as part of their daily lives. Finally, researchers need to facilitate developing diet and exercise interventions that address weight gain from atypical antipsychotic medications and that consider the unique challenges faced by this population. Funding and SupportThis study was supported by a grant from Eli Lilly Canada (grant # F1D-CA-0048). AcknowledgementsWe thank Dr Joel Goldberg and Susan Gensey Hamilton Program for Schizophrenia, together with Michael Boyle and Natalie Cousineau for their scientific contributions to this paper. We also thank Dr Oded Bar-Or, and Randy Calvert, Clinic Manager, Exercise Physiologist at the Children’s Exercise and Nutrition Centre, Hamilton Health Sciences; and the Hamilton YMCA and staff. References1. Colvin RH, Olson S B. A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaining the loss. Addict Behav 1983;8:287–95. 2. Hoiberg A, Berard S, Watten RH, Caine C. Correlates of weight loss in treatment and at follow-up. Int J Obes 1984;8:457–65. 3. Marston AR, Criss J. Maintenance of successful weight loss: incidence and prediction. Int J Obes 1984;8:435–9. 4. Greenberg I, Chan S, Blackburn GL. Nonpharmacologic and pharmacologic management of weight gain. J Clin Psychiatry 1999;60(Suppl 21):S31–S36. 5. Stanniland C, Taylor D. Tolerability of atypical antipsychotics. Drug Safe 2000;22:195–214. 6. Tollefson GD, Beasley CM Jr, Tamura RN, Tran PV, Potvin JH. Blind, controlled, long-term study of the comparative incidence of treatment-emergent tardive dyskinesia with olanzapine or haloperidol. Am J Psychiatry 1997;154:1248–54. 7. Tran PV, Hamilton SH, Kuntz AJ, Potvin JH, Andersen SW, Beasley C Jr, and others. Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. J Clin Psychopharmacol 1997;17:407–18. 8. Wirshing DA, Wirshing WC, Kysar L, Berisford MA, Goldstein D, Pashdag J, and others. Novel antipsychotics: comparison of weight gain liabilities. J Clin Psychiatry 1999;60:358–63. 9. Taylor DM, McAskill R. Atypical antipsychotics and weight gain a systematic review. Acta Psychiatr Scand 2000;101:416–32. 10. Kawachi I. Physical and psychological consequences of weight gain. J Clin Psychiatry 1999;60(Suppl 21):S5–S9. 11. Bernstein JG. Psychotropic drug induced weight gain: mechanisms and management. Clin Neuropharmacol 1988;11(Suppl 1):S194–S206. 12. Osser DN, Najarian DM, Dufresne RL. Olanzapine increases weight and serum triglyceride levels. J Clin Psychiatry 1999;60:767–70. 13. Hockey RV. Physical fitness: the pathway to healthful living. 7th ed. St. Louis: Mosby; 1993. 14. Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, and others. Stages of change and decisional balance for 12 problem behaviors. Health Psychol 1994;13(1):39–46. Author(s)Manuscript received December 2002, revised, and accepted March 2003. This paper was previously presented as an abstract at the 14th Annual Department of Psychiatry and Neurobehavioural Sciences Research Day April 18, 2002; Hamilton Convention Centre, Hamilton (ON). 1. Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario; Director, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division, Hamilton, Ontario. 2. Family Educator, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division, Hamilton, Ontario. 3. Nurse, Psychotic Disorders Clinic, Hamilton Health Sciences, McMaster Division, Hamilton, Ontario. Address for correspondence: Dr S Archie, 3G Out Patient Psychiatry Clinic, McMaster University Medical Centre, 1200 Main Street West, Hamilton, ON L8N 3Z5. e-mail: murphjoa@hhsc.ca
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