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Transdiagnostic efficacy of a group exercise intervention for outpatients with heterogenous psychiatric disorders: a randomized controlled trial

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Background: Exercise efficaciously reduces disorder-specific symptoms of psychiatric disorders. The current study aimed to examine the efficacy of a group exercise intervention on global symptom severity and disorder-specific symptoms among a mixed outpatient sample. Methods: Groups of inactive outpatients, waiting for psychotherapy, with depressive disorders, anxiety disorders, insomnia, and attention-deficit/hyperactivity disorders were randomized to a manualized 12-week exercise intervention, combining moderate to vigorous aerobic exercise with techniques for sustainable exercise behaviour change (n = 38, female = 71.1% (n = 27), Mage = 36.66), or a passive control group (n = 36, female = 75.0% (n = 27), Mage = 34.33). Primary outcomes were global symptom severity and disorder-specific symptoms, measured with the Symptom Checklist-90-Revised and Pittsburgh Sleep Quality Index pre- and post-treatment. Secondary outcome was the self-reported amount of exercise (Physical Activity, Exercise, and Sport Questionnaire), measured pre-treatment, intermediate-, and post-treatment. Intention-to-treat analyses were conducted using linear mixed models. Linear regressions were conducted to examine the effect of the change of exercise behaviour on the change of symptoms. Results: The intervention significantly improved global symptom severity (d = 0.77, p = .007), depression (d = 0.68, p = .015), anxiety (d = 0.87, p = .002), sleep quality (d = 0.88, p = .001), and increased the amount of exercise (d = 0.82, p < .001), compared to the control group. Post-treatment differences between groups were significant for depression (d = 0.63, p = .031), sleep quality (d = 0.61, p = .035) and the amount of exercise (d = 1.45, p < .001). Across both groups, the reduction of global symptom severity was significantly predicted by an increase of exercise (b = .35, p = .012). Conclusions: The exercise intervention showed transdiagnostic efficacy among a heterogeneous clinical sample in a realistic outpatient setting and led to sustained exercise behaviour change. Exercise may serve as an efficacious and feasible transdiagnostic treatment option improving the existing treatment gap within outpatient mental health care settings. Trial registration: The study was registered on ClinicalTrials.gov (ID: NCT03542396 , 25/04/2018).
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R E S E A R C H Open Access
Transdiagnostic efficacy of a group exercise
intervention for outpatients with
heterogenous psychiatric disorders: a
randomized controlled trial
Johanna-Marie Zeibig
1*
, Britta Seiffer
1
, Gorden Sudeck
1
, Inka Rösel
2
, Martin Hautzinger
3
and Sebastian Wolf
1,3
Abstract
Background: Exercise efficaciously reduces disorder-specific symptoms of psychiatric disorders. The current study
aimed to examine the efficacy of a group exercise intervention on global symptom severity and disorder-specific
symptoms among a mixed outpatient sample.
Methods: Groups of inactive outpatients, waiting for psychotherapy, with depressive disorders, anxiety disorders,
insomnia, and attention-deficit/hyperactivity disorders were randomized to a manualized 12-week exercise
intervention, combining moderate to vigorous aerobic exercise with techniques for sustainable exercise behaviour
change (n= 38, female = 71.1% (n=27),M
age
= 36.66), or a passive control group (n= 36, female = 75.0% (n=27),
M
age
= 34.33). Primary outcomes were global symptom severity and disorder-specific symptoms, measured with the
Symptom Checklist-90-Revised and Pittsburgh Sleep Quality Index pre- and post-treatment. Secondary outcome was
the self-reported amount of exercise (Physical Activity, Exercise, and Sport Questionnaire), measured pre-treatment,
intermediate-, and post-treatment. Intention-to-treat analyses were conducted using linear mixed models. Linear
regressions were conducted to examine the effect of the change of exercise behaviour on the change of symptoms.
Results: The intervention significantly improved global symptom severity (d=0.77,p=.007),depression(d=0.68,
p=.015),anxiety(d=0.87,p= .002), sleep quality (d=0.88,p= .001), and increased the amount of exercise (d=0.82,
p< .001), compared to the control group. Post-treatment differences between groups were significant for depression
(d=0.63,p= .031), sleep quality (d=0.61,p= .035) and the amount of exercise (d=1.45,p<.001).Acrossbothgroups,
the reduction of global symptom severity was significantly predicted by an increase of exercise (b=.35,p= .012).
Conclusions: The exercise intervention showed transdiagnostic efficacy among a heterogeneous clinical sample in a
realistic outpatient setting and led to sustained exercise behaviour change. Exercise may serve as an efficacious and feasible
transdiagnostic treatment option improving the existing treatment gap within outpatient mental health care settings.
Trial registration: The study was registered on ClinicalTrials.gov (ID: NCT03542396, 25/04/2018).
Keywords: Exercise, Transdiagnostic efficacy, Depression, Anxiety disorders, Insomnia
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* Correspondence: Johanna-marie.zeibig@uni-tuebingen.de
1
Department of Education & Health Research, Faculty of Economics and
Social Sciences, Institute of Sports Science, University of Tuebingen, 72074
Tuebingen, Germany
Full list of author information is available at the end of the article
Zeibig et al. BMC Psychiatry (2021) 21:313
https://doi.org/10.1186/s12888-021-03307-x
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Background
In 2019, psychiatric disorders affected about 15.6%
(point prevalence) of the population in Germany [1].
Psychiatric disorders result in a considerable burden of
disease, accounting for 6.4% of disability-adjusted life
years (DALYS) [1] and increasing the risk for cardiovas-
cular diseases [2]. The most frequent and burdensome
psychiatric disorders are depressive disorders (point
prevalence: 4.3%), anxiety disorders (point prevalence:
7.1%), including obsessive compulsive disorders (OCD)
and posttraumatic-stress disorder (PTSD), and insomnia
(point prevalence: 4%) [1,3]. Epidemiological studies
demonstrated that comorbidity across these disorders is
rather the rule than the exception [4]. Additionally, these
disorders show a comorbidity with other psychiatric dis-
orders, such as attention deficit hyperactivity disorder
(ADHD) [5]. Comorbidity is related to an increased im-
pairment, a worse prognosis and stronger chronicity of
symptoms compared to people affected by one single
mental disorder [68]. The high prevalence and burden
of psychiatric disorders as well as their comorbid occur-
rence, emphasize the substantial need for treating psy-
chiatric disorders. However, in Germany, only 10% of all
individuals with psychiatric disorders receive evidence-
based treatment and only 2.5% receive psychotherapy
[9]. Furthermore, in 2018, the average waiting time for
psychotherapeutic treatment was approximately 5
months [10]. The high necessity for treatment, on the
one hand, and deficits in mental health care, on the
other hand, illustrates the severe gap between people in
need for treatment and those actually receiving it [11].
This treatment gap aggravates the burden of psychiatric
disorders because the absence or delay in treatment can
lead to worsening and chronicity of symptoms and add-
itionally to the development of comorbid diagnoses [10].
Thus, there is a demand for treatment that can improve
this treatment gap by being applicable and efficacious to
individuals who meet criteria for one or more clinical
diagnoses and also for groups of heterogenous disorders.
In addition, this treatment would need to be easily and
fast accessible (i.e., efficient) to increase the number of
people receiving treatment.
The mental health care is dominated by treatments,
that are tailored to specific disorders (i.e., disorder-
specific treatments) [12] and are usually conducted in
individual format rather than in group format [13].
However, considering clinical reality with heterogenous
and also comorbid presentations of diagnoses [4], the
conduction of those treatments is not efficient because
multiple treatment protocols for different specific
disorders need to be applied [12]. Furthermore,
disorder-specific treatments no longer correspond to
recent evidence supposing that underlying shared com-
mon etiological and maintenance processes rather than
specific diagnoses should be considered when treating
psychiatric disorders [12,14].
To address these underlying mechanisms instead of
specific disorders, transdiagnostic psychological treat-
ments, that [] apply the same underlying treatment
principles across mental disorders without tailoring the
protocol to specific diagnoses([26], p.21) have been
developed [27,28,29,30,31]. Recent meta-analyses [27
31], that evaluated the efficacy of transdiagnostic psycho-
logical treatments, such as transdiagnostic cognitive be-
havior therapy (CBT) [27], among patients with depressive
disorders and/or anxiety disorders over comparison or
control interventions (i.e., diagnosis-specific intervention
control, treatment-as-usual, or a waitlist control), demon-
strated moderate to large effect sizes. This suggests that
transdiagnostic treatments can efficaciously augment
dominating disorder-specific treatments [12].
There is a body of evidence assuming that exercise,
defined as physical activity that is planned, structured,
and repetitive, with the primary aim to improve or main-
tain physical fitness [32] might represent a potential
transdiagnostic treatment for depressive disorders, anx-
iety disorders, insomnia and ADHD. Findings of a recent
meta-analysis [33] investigating the effects of exercise on
underlying processes of these psychiatric disorders (i.e.,
anxiety sensitivity, distress tolerance, stress reactivity,
and general self-efficacy) revealed a large effect of
exercise on reducing anxiety sensitivity, a moderate ef-
fect on increasing general self-efficacy and a small effect
on reducing stress reactivity. Similarly, a recent meta-
analysis of randomized controlled trials (RCTs) [34],
which examined the impact of exercise on sleep quality
among people with psychiatric disorders, revealed a large
beneficial effect on the improvement of sleep quality.
Supporting the assumption of the transdiagnostic effi-
cacy of exercise, results of numerous systematic reviews
and meta-analyses have suggested moderate to large
disorder-specific effects of exercise on depressive disor-
ders [35,36], anxiety disorders [37,38], insomnia [39,
40]andADHD[41,42] over non-active [37,39], or ac-
tive and non-active controls [35,36,38,40,41].
Exercise conducted two to three times per week, for
approximately 10 weeks, at a minimum of moderate in-
tensity and a duration of 30 min, partially supervised or
non-supervised, solely aerobic or aerobic combined with re-
sistance training, are key components of previous disorder-
specific exercise interventions and seem to be associated
with optimal therapeutic efficacy among patients with spe-
cific disorders [33,35,37,43]. These beneficial effects, such
as the reduction of depressive symptoms, seem to be only
sustainable when exercise is conduced and maintained on a
regular base. In an exercise trial [44], the antidepressant ef-
fect of exercise was compared to those of psychopharma-
cotherapy in patients with depressive disorders. Both
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conditions showed similar improvements in depressive
symptoms. In the one-year follow up study, however, this
effect was only maintained for those participants who en-
gaged in exercise on a regular base [45]. Exercise interven-
tions combined with behavior change techniques (BCTs),
that increase motivation and volition for exercise seem to
increase the initiation and maintenance of exercise among
healthy and psychiatric samples [46,47,48,49].
Despite of the promising evidence of the efficacy of
exercise among specific disorders and underlying pro-
cesses across disorders, to the best of our knowledge,
the effects of exercise have never been investigated
across a broad range of diagnostically heterogeneous
and a highly comorbid clinical sample in a realistic
outpatient setting. Furthermore, as far as we know,
there is no exercise trial that includes heterogenous
disorders and assessed global symptom severity with a
reliable and clinical measure.
Therefore, the manualized group exercise intervention,
named ImPuls[50], was developed. The intervention
was developed for inactive outpatients, waiting for psy-
chotherapeutic treatment in German health care settings
in outpatient units and practices, suffering from one or
more diagnoses of depressive disorders, anxiety disor-
ders, insomnia, and ADHD. The exercise intervention
integrates the most recent findings about optimal mo-
dalities of exercise for therapeutic efficacy for the
targeted disorders and sustainable behavior change by
integrating behavior change techniques (BCTs). All
components of this intervention are tailored to the care
reality of outpatients with psychiatric disorders to offer
an efficient treatment option in the outpatient mental
health care setting: 1) including a broad range of
heterogenous diagnoses for which prior research has
demonstrated therapeutic efficacy, 2) conducting the
intervention in group format, 3) short duration (i.e., 4
weeks of supervised sessions, 8 weeks non-supervised
exercise) to be feasible during waiting times for
psychotherapy.
The primary hypothesis was that participants of the
intervention group would demonstrate lower global
symptom severity and disorder-specific symptoms
(depression, anxiety, sleep quality) at post-treatment
assessment compared to a passive control group. The
secondary hypothesis was that participants of the
intervention group would demonstrate a significant
larger amount of exercise at intermediate- and post-
treatment assessment compared to the control group.
It was further hypothesized that the increase of the
amount of exercise from pre- to post-treatment as-
sessment would predict the reduction of global symp-
tom severity and disorder-specific symptoms from
pre- to post-treatment assessment across both treat-
ment arms.
Methods
Study design
The study was conducted at the University of Tuebingen.
Active enrollment lasted from April 2018 to October
2019. The study was registered on ClinicalTrials.gov (ID:
NCT03542396, 25/04/2018) and approved by the local
ethics committee for psychological research (Az_Wolf_
2018_0108_99). A block-randomized (allocation ratio 1:1)
parallel trial with two treatment arms (intervention group,
control group) and three measurement points (pre-, inter-
mediate-, post-treatment assessment) was conducted. Pri-
mary outcomes were assessed at pre- and post-treatment
assessment; secondary outcome at pre-, intermediate- and
post-treatment assessment. The study was reported ac-
cording to the Consolidated Standards of Reporting Trials
(CONSORT) statement [51].
Recruitment and participants
Recruiting was performed at the outpatient clinic of the
University of Tuebingen, medical and psychotherapists
offices, and by media advertising. Inclusion criteria were
age between 18 and 65 years, fluent in German, no med-
ical contraindications for exercise (participants needed
to receive a medical consultation prior to the interven-
tion that confirmed participants ability to exercise), on a
waiting-list for outpatient psychotherapy and diagnosed
according to DSM-IV-TR with at least one of the follow-
ing disorders: depressive disorders (F32, F33, F34.1),
anxiety disorders (F40.0, F40.1, F40.2, F41.0, F41.1,
F41.2, F42, F43.1, insomnia (F51.0), and ADHD (F90.0,
F90.1, F98.8). Exclusion criteria included: acute sub-
stance use disorders (F10.2, F11.2, F12.2, F13.2, F14.2,
F15.2, F16.2, F18.2, F19.2), chronic pain disorder (F45.1),
eating disorders (lifetime; F50), bipolar disorder (lifetime;
F31), antisocial personality disorder (F60.2), borderline
personality disorder (F60.3), acute suicidal tendencies,
regular exercise (30 min/week), change (i.e., reduction
and increase) of psychopharmaceuticals (2 months).
Any change in treatment led to a withdrawal from the
study.
The sample size was determined a-priori through
power analysis, using G*Power ([52], v. 3.1.9.7.). A
moderate to large effect (Cohensd= 0.74) of the mean
post-difference between the two groups for the primary
outcome was expected. Effect estimation was the median
of the effect of exercise on disorder-specific symptoms
of depressive disorders, anxiety disorders and insomnia.
Since a small number of eligible participants with
ADHD was expected, the effect of exercise on symptoms
of ADHD was not included in the effect estimation.
Effect sizes were derived from the most recent meta-
analyses and RCTs available at the time of trial design
[36,40,53]. With significance level: α= .05, Power: 1-
β= .80, allocation ratio N2/N1: ε= 1, the required
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sample size for a two-tailed t-test for independent sam-
ples was N= 60. With an expected dropout rate of 18%
for a clinical sample in an RCT [38], the total sample re-
sulted in N= 71. This resulted in a group size of ap-
proximately n= 36 for each group.
Randomization
Randomization was performed when the maximum of
participants for one treatment group (n=510) was
eligible and/or when remaining waiting time for psycho-
therapy was shorter than intervention period (3
months). Participants were assigned a code, which was
sent to a research assistant. They were randomly
assigned to a group, based on a randomization table,
stratified by age and symptom severity (Global Assess-
ment of Functioning Scale, GAF) for each group, using
MATLAB (9.6.0, R2019a). The study therapist received
the allocation information, matched the codes to partici-
pants and informed them of their group allocation.
Procedure
Psychologists performed a preliminary telephone screen-
ing of eligibility criteria. Eligible participants were invited
to the University of Tuebingen where they first com-
pleted a demographic questionnaire. Research assistants,
who were trained in the conduction of structured clin-
ical interviews, conducted the structured clinical inter-
view for DSM-IV (SCID) [54] for eligibility criteria.
ADHD was diagnosed by DSM-IV criteria through the
Homburg ADHD Scales for Adults (HASE) [55]. Primary
insomnia was diagnosed by DSM-IV criteria combined
with the Pittsburgh Sleep Quality Index (PSQI) [56].
Participants signed an informed consent form and com-
pleted online questionnaires via a secure online survey
software Sosci Survey [57] prior to randomization. This
pre-treatment assessment was conducted on an average
of 23.15 days (SD = 22.19) prior to the start of the
intervention.
Ten groups of five-to-ten participants were sequen-
tially allocated to the intervention group or control
group. The intervention group completed the exercise
intervention, while the control group did not receive any
treatment. At week 9 of the intervention (intermediate-
treatment assessment), participantsamount of exercise
was assessed. No other assessments were conducted at
this assessment point. Intermediate-treatment assess-
ment was scheduled at week 9 of the intervention
because it was middle of the non-supervised time. The
non-supervised intervention period started at week 5 of
the intervention and lasted 8 weeks in total.
One-to-two weeks after intervention (post-treatment
assessment), the same procedure of the pre-treatment as-
sessment was performed. The SCID was also conducted
again at post-treatment assessment by an outcome
assessor (research assistants, who were trained in the
conduction of structured clinical interviews) that was
blind to group assignment. Afterwards, the control
group received 50as a compensation for their time. All
participants were offered preferential psychotherapy at
the outpatient clinic in Tuebingen after post-treatment
assessment. The final post-treatment assessment was
conducted in October 2019.
Assessments
Primary outcomes
Global symptom severity Global symptom severity was
measured by the Global Severity Index (GSI) of the
German version of the self-reported questionnaire
Symptom Checklist-90-Revised (SCL-90-R [58];). The
GSI comprises the average distress rating on all symp-
tom scales and ranges from 0 to 4. Higher scores indi-
cate higher distress. Clinically relevant changes are
defined as a change on the GSI of at least 0.26 [58].
Among patients with affective disorders, the GSI has
demonstrated good internal consistency (α= .97) and
construct validity (r= .77) [59]. The internal consistency
in the current study was α= .97 for the GSI.
Depression and anxiety Depression and Anxiety were
measured by the sub scores Depression and Anxiety of
the self-reported questionnaire SCL-90-R [58]. Items of
the depression sub score ask participants for symptoms
of depression (e.g., How much did you suffer from a de-
crease in your interest or pleasure in sexuality in the
past few days?) and items of the anxiety sub score for
symptoms of anxiety (e.g., How much did you suffer
from nervousness or inner trembling in the past days?).
Scales ranges from 0 to 4 with higher scores indicating
higher distress. Symptoms are clinically raised when T-
values are 60. Among patients with affective disorders,
the depression scale (α= .89) and anxiety scale (α= .87)
have demonstrated internal consistency and construct
validity (r= .80 for depression and r= .61 for anxiety)
[59]. The internal consistency in the current study was
α= .91 for depression and α= .90 for anxiety.
Sleep quality Sleep Quality was measured by the global
sleep quality score of the German version of the self-
reported questionnaire Pittburgh Sleep Quality Index
(PSQI [56];). The global sleep quality score is the sum of
seven sleep component scores (range of component
scores: 03): subjective sleep quality (Over the last four
weeks, how would you rate your overall sleep quality?),
sleep latency (e.g., Over the last four weeks, how long
have had it usually take you to fall asleep at night?),
sleep duration (e.g., Over the last four weeks, how many
hours have you actually slet per night?), habitual sleep
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efficiency (e.g., Over the last four weeks, what time have
you usually gotten up in the morning?), sleep distur-
bances (e.g., Over the last four weeks, how often have
you had a bad nights sleep because you couldnt fall
asleep within 30 minutes?), use of sleeping medications
(e.g., Over the last four weeks, how often have you
taken sleeping pills (prescribed by a doctor or over-the-
counter)?), and daytime dysfunction (e.g., Over the last
four weeks, how often have you had difficulty staying
awake, such as while driving, eating, or attending social
events?). The global sleep quality score can vary from 0
to 21 with a cut-off score of 5, identifying clinically
raised sleep impairment [56]. It has shown a high sensi-
tivity (98.7%) and specificity (84.4%) in identifying in-
somnia [60]. In the literature, the internal consistency
for the global sleep quality score was α= .77 [61]. In the
current study, it was α= .67.
Secondary outcome: exercise
The amount of exercise was measured using the self-
reported exercise activity index of the physical activity,
exercise, and sport questionnaire (BSA questionnaire
[62];). Participants specify whether they have engaged in
regular exercise in the past 4 weeks (Have you engaged
in regular exercise in the past 4 weeks?). If they have
engaged in regular exercise, participants were asked to
specify the type (What kind of exercise activity (ies)
have you engaged in?), frequency and duration (I have
engaged in activity x approximately times in the past
four weeks, every time for approximately minutes)of
it. The exercise activity index indicates the average
minutes of exercise per week. The BSA questionnaire
can validly assess changes in exercise behavior. Data of
reliability is not available [62] and could not be analyzed
for the current study it because this scale consists of one
item only.
Further assessments
Further measures (self-reported questionnaires),
described in the trial registration, but not included in
the current evaluation, were the Sleep Questionnaire B-
Revised version (SF-B [63];), Perceived Stress Scale (PSS
[64];), 36-Item Short Form Health Survey (SF-36) (SF-36
[65];), Self Concordance of Sport- and Exercise-related
Goals Scale (SKK-Scale [66];), Scales that assess motiv-
ation and volition for exercise [67], and Physical
Activity-related Health Competence Questionnaire [68].
Accelerometer derived exercise at seven consecutive
days was assessed. 5-min resting heart rate variability
was assessed by a trained research assistant.
Exercise intervention
The 12-week exercise intervention ImPuls[69] was
conducted in a group format of three to four
participants and divided into a supervised and non-
supervised period. Behaviour change techniques (BCTs),
such as self-efficacy, goal setting, self-monitoring, forma-
tion of concrete exercise plans and coping planning,
were integrated to promote sustained exercise behaviour
change [49,70]. Intervention contents are displayed in
Fig. 1and Table 1.
Supervised period (week 04)
Participants took part in a combination of supervised
running session and group meetings with a total dur-
ation of 120 min. One supervised session is conducted
during week 0 (introduction to the intervention), three
supervised sessions during the second week, two super-
vised sessions plus one non-supervised exercise during
week 24, respectively. Running lasted 30 min and
participants could choose a standardized interval-based
training or endurance training. Both training methods
were conducted with moderate intensity, which was
tracked by a heart rate monitor (Polar Electro GmbH; A
300) combined with a chest strap (Polar Electro GmbH;
H7) and the Borg Rating of Perceived Exertion (RPE)
Scale [71]. Moderate intensity was defined as 60 to 80%
of maximum heart rate, subtracting age from 220 [72]
and from nine to 14 on the RPE Scale [71]. Participants
engaged in additional 30-min, moderate-intensity, non-
supervised exercise.
Non-supervised period (week 512)
During the non-supervised period, participants engaged
in 30-min, moderate-intensity, non-supervised exercise
two to three times a week, which was accompanied by
an activity diary and weekly phone calls with one study
therapist, intending to maintain motivation, volition, and
adherence to exercise. A session for participants
supporters (e.g., friends, partner) was scheduled in week
5 to inform them about the possibilities to aid the par-
ticipants in transforming their intentions into action. A
final group meeting with a running session took place in
week 12 in order to exchange experiences and to en-
courage participants to maintain regular exercising.
Attendance and adherence
Participants performed 30 min non-supervised exercise if
they missed a supervised running session. Contents of
group meetings were repeated in one-to-one sessions
(by phone or face-to-face). The assessment of the
amount of exercise (see Procedure) served as a measure
of adherence during the non-supervised period (see
Table 3).
Therapists
All main therapists were masters degree psychologists
with either fully approved in psychological
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psychotherapy or in advanced postgraduate training for
CBT. Assistant therapists were graduate students of
psychology. All therapists were trained in the back-
ground and contents of ImPuls und supervised by an ex-
ercise therapist and a psychotherapist.
Potential risks and benefits of the intervention
Most common risks associated with exercise are cardio-
vascular events and musculoskeletal injuries [73]. Inter-
mediate and long-term potential benefits of exercise are
improved physical health, such as prevention of diabetes
(e.g., [74]) and improved mental health, such as the
reduction of depressive symptoms (e.g., [75]). Further-
more, majority of individuals are exposed to greater risk
by not exercising. Indeed, sedentary behavior seem to be
associated with a higher risk to develop mental disorders
[76,77] and reduced physical health [78]. Since all par-
ticipants of the current intervention needed to receive a
medical consultation prior to the intervention, the po-
tential risk of exercise on physical health was minimized.
Therefore, potential benefits seemed to outweighs the
risks of participation in the study.
Data diagnostics
Individuals from both study arms, who fulfilled any
exclusion criteria (i.e., change of treatment, contraindica-
tions for exercise) during the intervention, were ex-
cluded from post-data collection, 18.1% (n= 13). Since
the current study contained exclusion criteria that could
change during study participation (e.g., change of treat-
ment), data from participants, who did no longer meet
eligibility criteria needed to be excluded from post-data
collection in order to reduce the risk of bias in the inter-
vention effect estimate [79]. Missing data was assessed at
Fig. 1 Intervention procedure of the group exercise intervention. Dark grey boxes represent group meetings combined with supervised aerobic
exercise (starting session 3) and the supporterssession (session 14 in week 5). Session 1 contains an introduction into the intervention. Session 15 is
conducted in week 12. Light grey boxes represent non-supervised exercises or resistance training, which can be conducted as participantsfirst non-
supervised exercise (session 6). The phone represents the weekly phone contact from week 512. Week 12 mainly aimed to increase motivation,
week 24 mainly increase volition. Week 512 aimed to transfer motivation and volition for exercise into participantsdaily life routines
Table 1 Overview of behaviour change techniques of the
group exercise intervention
Focus Technique
Motivational (mainly
week 12)
Education about positive and negative
effects of exercise
Education about optimal modalities of
exercise to experience positive psychological
effects
Selection of a preferred activity
Goal setting
Self-monitoring of goal achievement
Reflection about positive experiences/effects
with/of exercise
Volitional (mainly week
34)
Identification of barriers to exercise
Techniques to overcome barriers
Social support (intervention group and
trainers)
Exercise self-monitoring (optimal modality)
Motivational and
volitional (week 512)
Social support (family, friends, trainer)
Self-monitoring of goal achievement
Exercise self-monitoring (optimal modality)
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scale level. Linear mixed models, using maximum likeli-
hood estimations, were conducted to handle missing
data (also participantsdata of those who were excluded
from post-data-collection). Linear mixed models, based
on all observed data, can be a valid and unbiased
method to handle data that is missing at random [80].
Potential outliers were identified through three mea-
sures: Leverage, Cooks Distance, and Studentized Resid-
uals. Cases with greater than three time the average
leverage, cooks distance greater than 1, and studentized
residuals greater than 3 [81,82], were considered as po-
tential outliers or influential data points. To evaluate the
influence of potential outliers on results of linear mixed
models, they were calculated again without cases that ei-
ther exceeded the cut-off value of all three measures, or
exceeded the cut-off values of cooks distance and lever-
age, or exceeded the cut-off value of cooks distance.
Post-difference and interaction-effect sizes were then
compared to those of linear mixed models including the
complete data set.
Assumptions of linear mixed models and linear regres-
sions (i.e., linearity, normality of the residuals, homosce-
dasticity, and multicollinearity) were visually inspected.
If residuals of linear mixed models were not normally
distributed, data was log-transformed.
Analytic strategy
For data preparation the Statistical Package for Social
Science (IBM SPSS, Inc., Chicago, IL, USA, version 26)
was used. Statistical analyses were carried out using R
(version 4.0.3) and RStudio (version 1.1.453). Descriptive
statistics were used to analyze sample characteristics and
dropout rates. Baseline differences between groups and
between those that completed the study versus dropped
out were analyzed using two-tailed t-tests for independ-
ent samples (continuous variables), Chi-scared tests or
fishers exact tests (categorical variables).
Differences between groups on primary and secondary
outcomes changes were analyzed as intention-to-treat
(ITT) analysis with linear mixed models using the lme4
package [83] in R. Models used maximum likelihood as
the estimation technique. Models included treatment
group,time point and time point-by-treatment group
interaction as fixed effects. Intercepts were included as
random effects. An unstructured covariance matrix
was assumed. Post-hoc tests for post-treatment-
differences between groups were carried out using
two-tailed t-test for independent samples. For post-hoc
tests of the secondary outcome, a Bonferroni correc-
tion was used. Effect sizes for differences between
groups (intermediate-, post-treatment-difference ef-
fects and interaction effects) were calculated according
to Cohensd[84].
An additional analysis inspected clinically relevant
changes of participantssymptomatology. Clinically rele-
vant changes were defined as a change on the GSI from
pre-treatment to post-treatment assessment of at least
0.26 [58].
Sufficient statistical power enabled exploratory ana-
lyses that examined the efficacy of exercise on depres-
sion for subgroups of participants diagnosed with
depressive disorders. Additional exploratory analysis
(per-protocol analysis) tested the predictive value of the
change of the amount of exercise on primary outcomes
changes. Linear regressions were calculated with change
of exercise (post-treatment assessment pre-treatment
assessment) as a predictor variable and primary out-
comes changes (pre-treatment assessment post-
treatment assessment) as criterion variables.
Results
Participant flow during the study
In total, 106 individuals were assessed for eligibility.
Of those assessed, 30.2% (n= 32) were excluded and
69.8% (n= 74) were eligible for participation. Those
eligible were randomly assigned to the intervention
group, 51.3% (n= 38), or control group, 48.7% (n=
36). 5.3% (n= 2) of participants of the intervention
group were removed from the analysis due to a
wrong diagnosis at pre-treatment assessment (comor-
bid lifetime eating disorder, 2.6% (n= 1), and a co-
morbid alcohol use disorder, 2.6% (n=1) [79]. This
led to an ITT efficacy group of N= 72 (50.0% (n=36)
of patients in the intervention group vs. 50.0% (n=
36) in the control group) (see Fig. 2).
Participant characteristics at baseline
Baseline characteristics of the studied sample are reported
in Table 2. There were no significant baseline differences
between intervention group and control group. Dropout
rates of the control group were higher compared to the
intervention group, but not statistically different. Com-
pared to the intervention group, participants of the con-
trol group dropped out more frequently due to treatment
change without reaching statistical significance (see
Table 2and Fig. 2). There were no significant baseline
differences between study completers and dropouts
(Additional file 1). There were no serious adverse events.
Statistics and data analysis
Missing data was missing completely at random
(MCAR) (χ
2
(14) = 12.33, p= .580). 106 (14.7%) values of
primary and secondary outcomes were incomplete. Per-
protocol analyses for each primary and secondary
outcome were conducted as sensitivity analyses, using
linear mixed models (Additional file 2), to examine
the robustness of the results.
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Ten cases were detected as potential outliers in the
linear mixed model with the GSI (SCL-90-R) as criterion
variable and four cases in the linear mixed model with
the global sleep quality score (PSQI) as criterion vari-
able. No cases were detected as potential outliers in the
mixed models with exercise (BSA questionnaire) as cri-
terion variable. Excluding potential outliers did not
change direction, nor significance of intervention effects
(Additional file 4). Intervention effects on the global
sleep quality score increased from moderate to large
effect size (cohens d for post-treatment-difference be-
tween groups) when potential outliers were excluded.
Therefore, potential outliers were not excluded from
analyses.
Efficacy of the intervention
Results of all primary and secondary outcomes and sub-
group analysis, including effect sizes, are presented in
Fig. 2 CONSORT flow diagram: profile and enrollment and flow through the randomized controlled trial of group exercise intervention versus a
passive control group for individuals with mental disorders
Zeibig et al. BMC Psychiatry (2021) 21:313 Page 8 of 17
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Table 3. The interaction effect of group by time was sig-
nificant for global symptom severity, F(1, 53) = 7.93, p=
.007, 95%CI[0.50,- 0.08], depression, F(1, 55) = 6.30,
p= .015, 95%CI[0.82, 0.09], anxiety, F(1, 54) = 10.12,
p= .002, 95%CI[0.36, 0.08], and sleep quality, F(1,
58) = 11.24, p= .001, 95%CI[4.68, 1.19], with larger
decreases in the intervention group. Post-treatment
difference effects were significant for depression, t
Table 2 Baseline demographic and clinical characteristics of participants
Intervention Group Control Group Intervention Group
Compared With Control
Group (N= 72)
(N= 36) (N= 36)
Measure N % N % χ
2
df p
Female 25 69.4 27 75.0 0.28 1 .599
Married or partnered 25 69.4 24 66.7 0.06 1 .801
High school 31 86.1 25 69.4 2.89 1 .089
Employment
a
33 94.3 31 88.6 .673
h
Diagnosis .866
h
Depressive disorders (single)
b
13 36.1 11 30.6
Depressive disorders (comorbid with
anxiety disorders)
c
10 27.8 13 36.1
Panic disorder 2 5.6 2 5.6
Social anxiety disorder 2 5.6 2 5.6
Specific anxiety disorder 2 5.6 0 0.0
Generalized anxiety disorder 1 2.8 0 0.0
Agoraphobia 1 2.8 1 2.8
Obsessive-compulsive disorder 0 0.0 0 0.0
Obsessive-compulsive disorder and
social anxiety disorder
0 0.0 2 5.6
Post-traumatic stress disorder 1 2.8 2 5.6
Primary insomnia 3 8.3 3 8.3
Attention deficit hyperactivity disorder 1 2.8 0 0.0
Clinically raised symptoms (SCL-90-R, PSQI) 36 100.0 34 94.1 .493
h
Depression
d
, anxiety
d
, insomnia
e
21 58.3 17 47.2 0.89 1 .345
Receiving psychiatric drugs
f
18 50.0 20 57.1 0.36 1 .546
Dropout 7 19.4 14 38.9 3.29 1 .070
Treatment change
g
3 8.3 9 25.0 .111
h
Mean SD Mean SD t df p
Age (years) 37.33 14.23 34.33 12.39 0.95 68.69 .343
Global Severity Index (SCL-90-R) 1.06 0.63 1.02 0.61 0.27 69.91 .790
Sleep Quality (PSQI)
e
9.67 3.66 8.62 3.15 1.28 68.04 .204
Latency pre-treatment initiation (days) 21.94 17.21 24.36 26.44 0.46 60.15 .648
Note.SCL-90-R Symptom Checklist-90-Revised, PSQI Pittsburgh Sleep Quality Index
a
For employment, the number of participants was n= 35 for the intervention group and n= 35 for the control group because of incomplete data at
pre-treatment assessment.
b
Depressive disorders (single) includes all participants diagnosed with a single depressive disorder.
c
Depressive disorders (comorbid with anxiety disorders) includes all participants diagnosed with depressive disorder and comorbid anxiety disorders.
d
Depression and anxiety levels were classified as clinically raised when t-values of the sub-scales depression and anxiety of the SCL-90-R were greater or equal to
60 (reference group: healthy men, aged between 35 and 44).
e
Symptoms of insomnia were classified as clinically raised when the cut-off value of five of the total sum score of the PSQI were reached. For clinically raised
symptoms and sleep quality, the number of participants was 36 for the intervention group and 35 for the control group because of incomplete data at pre-
treatment assessment on the PSQI.
f
For receiving psychiatric drugs, the number of participants was n= 36 for the intervention group and n= 35 for the control group because of incomplete data at
pre-treatment assessment.
g
Treatment change is defined as the start of psychotherapy, inpatient treatment or psychopharmacological change.
h
Fishers exact test was used as a replacement for the chi-square test because the frequency of one or more cells was less than 5
Zeibig et al. BMC Psychiatry (2021) 21:313 Page 9 of 17
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(114) = 2.18, p= .031, and sleep quality, t(121) = 2.13,
p= .035, with lower scores in the intervention group.
Post-treatment difference effects for global symptom
severity, t(105) = 1.68, p= .096, and anxiety, t(110) =
1.88, p= .063, were moderate, with lower scores in the
intervention group, without reaching significance.
The interaction effect of group by time was significant
for the mean amount of exercise, F(2, 115) = 16.50,
p< .001, 95%CI [1.41, 3.61], with larger increases in the
intervention group. Bonferroni-corrected intermediate-
treatment difference effect, t(167) = 5.83, p< .001, and
post-treatment difference effect, t(170) = 5.04, p< .001,
were significant, with higher scores in the intervention
group.
Compared to participants of the control group, more
participants of the intervention group revealed clinically
significant changes of symptomatology, without reaching
statistical significance (χ
2
(1) = 3.61, p= .058.
In a subgroup of participants with depressive
disorders, the interaction effect was significant for
depression, F(1, 37.48) = 5.74, p= .022, 95%CI[1.01,
0.09], with larger decreases in the intervention
group. The Post-treatment difference in this subgroup
was significant, t(75) = 2.75, p= .008, with lower
scores in the intervention group (see Table 3). Across
both groups, the change of the mean amount of
exercise from pre- to post-treatment assessment
significantly predicted the change of global symptom
severity, b= .35, t(49) = 2.61, p= .012]. Predictions
Table 3 Marginal means, confidence intervals, effect sizes, and results of linear mixed models analyses
Intervention Group
(N= 36)
Control Group
(N= 36)
Change from Baseline in
Intervention Group
Compared With Control
Group (N= 72)
Measure and Assessment Point Mean SD 95% CI Mean SD 95% CI d
a
B 95% CI d
b
Global Severity Index (SCL-90-R) 0.30 0.50,-0.08 0.77**
Pre-treatment 1.06 0.59 0.87,1.26 1.02 0.59 0.83,1.22
Post-treatment 0.67 0.55 0.47,0.87 0.93 0.51 0.71,1.14 0.48
Depression (SCL-90-R) 0.46 0.82,-0.09 0.68*
Pre-treatment 1.57 0.85 1.29,1.85 1.60 0.85 1.32,1.88
Post-treatment 0.94 0.80 0.65,1.24 1.43 0.76 1.11,1.76 0.63*
Anxiety (SCL-90-R)
c
0.22 0.36,-0.08 0.87**
Pre-treatment 0.60 0.35 0.49,0.72 0.56 0.35 0.44,0.67
Post-treatment 0.36 0.33 0.24,0.48 0.53 0.31 0.40,0.67 0.53
Sleep Quality (PSQI) 2.94 4.68,-1.19 0.88**
Pre-treatment 9.67 3.31 8.57,10.76 8.67 3.29 7.57,9.77
Post-treatment 6.47 3.21 5.29,7.65 8.41 3.12 7.09,9.73 0.61*
Exercise (BSA questionnaire)
c
2.51 1.41,3.61 0.82***
Pre-treatment 1.82 1.82 1.22,2.42 1.72 1.82 1.12,2.33
week 9 4.68 1.80 4.00,5.35 1.74 1.79 1.04,2.45 1.64***
Post-treatment 4.12 1.80 3.46,4.78 1.53 1.77 0.78,2.27 1.45***
Exploratory Analysis (N= 47)
Intervention Group
(N= 23)
Control Group
(N= 24)
Change from Baseline in
Intervention Group
Compared With Control
Group (N= 47)
Depression (single and with comorbid
anxiety disorders) (SCL-90-R)
d
0.55 1.01,0.09 0.78*
Pre-treatment 1.84 0.79 1.51,2.17 2.00 0.78 1.68,2.32
Post-treatment 1.10 0.77 0.77,1.44 1.81 0.71 1.42,2.20 0.95**
Note.SCL-90-R Symptom Checklist-90-Revised, PSQI Pittsburgh Sleep Quality Index, BSA questionnaire Exercise Activity Index of the Physical Activity, Exercise, and
Sport Questionnaire
a
Cohens d for post- and intermediate-treatment effect.
b
Cohens d for the interaction effect.
c
Log-transformed data due to a skewed data distribution.
d
Participants with depression with and without comorbidities.
*p< .05. ** p< .01. ***p< .001
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fromthechangeofexerciseonthechangeof
disorder-specific symptoms across both groups and
for each group are displayed in Additional file 3.
Discussion
This RCT compared a group exercise intervention with
a passive control group among 72 inactive outpatients,
suffering from one or more diagnoses of depressive
disorders, anxiety disorders, insomnia, and ADHD.
Compared to the control group, the intervention was
efficacious in improving global symptom severity, de-
pression, anxiety and sleep quality as well as the amount
of exercise with moderate to large effect sizes. Post-
treatment difference effects were moderate to large on
depression, sleep quality and the amount of exercise.
Among participants diagnosed with depressive disorders,
the antidepressant effect of the exercise intervention was
larger compared to the entire mixed sample. Across both
groups, an increase in the amount of exercise predicted
the reduction of global symptom severity, indicating that
those patients who engaged in more exercise showed de-
creased symptom severity.
Efficacy of the intervention
Beneficial effects of the intervention on global symptom
severity suggest that the exercise intervention
efficaciously reduced symptoms across the included
heterogenous sample. On the one hand, there are few
studies that investigated the efficacy of exercise among
outpatients with heterogenous psychiatric diagnoses
[75]. On the other hand, the few existing studies
assessed physical health, rather than mental health as
primary outcomes [85]. Two RCTs assessed quality of
life [86] and general mental health [87] as secondary
outcome. Their results suggested improvements on qual-
ity of life (i.e., physical function score, social function,
emotional role) [86] but not on general mental health
(i.e., psychological distress and well-being) [87]. To the
best of our knowledge, there exists no study investigat-
ing the effects of exercise among a sample with
heterogenous diagnoses that include a clinical valid and
reliable measure to assess global symptom severity.
Whereas the intervention group revealed stronger im-
provements on global symptom severity, compared to
the control group, the post-treatment effect between
both groups was not significant. Since sample size calcu-
lation was based on large effects of exercise on disorder-
specific symptoms among included disorders, power
might have been to small to detect treatment effects on
global symptom severity across disorders at post-
treatment assessment.
Interaction effects of the current intervention on glo-
bal symptom severity are similar to those of recent
meta-analyses [27,28,29,30,31], evaluating the efficacy
of transdiagnostic psychological treatments among pa-
tients with depressive disorders and/or anxiety disorders
over comparison or control interventions (i.e., diagnosis-
specific intervention control, treatment-as-usual, or a
waitlist control). Results of these previous studies re-
vealed moderate to large effects on clinical measures
assessing symptom severity across included disorders
(i.e., depression-anxiety scales, quality of life).
Supporting the assumption of the transdiagnostic effi-
cacy of the intervention, our results demonstrated that
the intervention improved one underlying process across
included disorders with large effect size: poor sleep
quality [21,22]. This result is similar to a recent meta-
analysis of RCTs [34] which demonstrated large benefi-
cial effect of exercise on sleep quality among people with
various psychiatric disorders. Nonetheless, the analysis
included primarily RCTs assessing the effects of exercise
on sleep quality among study samples with specific diag-
noses. Only one RCT [88] included participants with a
primary diagnosis of a depressive disorder with and
without comorbid anxiety disorders. Similarly, another
recent meta-analysis [89] that investigated the effects of
exercise on various underlying processes across psychi-
atric disorders, mostly included participants with specific
diagnoses or even non-clinical samples. Thus, the
findings of our study therefore expand on the results of
recent meta-analyses by demonstrating effects on one
underlying process across a clinical sample with
heterogenous psychiatric disorders.
Correspondingly, our results suggest disorder-specific
efficacy by improving symptoms of depression, anxiety
and insomnia. The moderate antidepressant effect of the
intervention at post-treatment assessment is smaller
compared to prior meta-analytical findings suggesting a
large antidepressant effect of exercise, over non-active
controls [36]. In contrast to our study, prior studies in-
cluded samples with a primary diagnosis of a depressive
disorder only [36]. Although the large antidepressant ef-
fect among patients with a primary depressive disorder
have been consistently demonstrated in prior studies
[35,36], to the best of our knowledge, the antidepressant
effect of exercise among anxiety disorders, insomnia,
and ADHD has not been investigated yet. When analyz-
ing the antidepressant efficacy of our exercise interven-
tion among the subsample with a primary diagnosis of a
depressive disorder, the effect size is comparable to prior
studies [36]. The mean change of anxiety symptoms
among the intervention group across the entire mixed
sample was large, compared to the control group. Prior
exercise trials have reported moderate interaction effects
of exercise on anxiety symptoms among patients with
anxiety disorders, over non-active controls [38]. This re-
sult may suggest that the current exercise intervention
might have been more efficacious in reducing anxiety
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across heterogenous disorders than prior exercise trials
that included only anxiety disorders [38]. However, this
assumption needs to be considered with caution due to
different sample characteristics and exercise modalities.
The post-treatment difference effect between the
intervention group and control group on anxiety was
not statistically significant. As stated above, the power
analysis was based on the median effect size for
disorder-specific effects of exercise across depressive dis-
orders, anxiety disorders, and insomnia. Beneficial effects
of exercise on anxiety seem to be smaller than those for
depression [35] and insomnia symptoms [39]. Further-
more, it appears that effect sizes differ across different
anxiety disorders [37]. Therefore, the a-priori deter-
mined sample size might have been underestimated to
detect treatment effects on anxiety across the
heterogenous sample. The large post-treatment effect of
exercise on sleep quality among the intervention group,
compared to the control group, is comparable to prior
meta-analytical findings investigating the effect of
exercise on sleep quality in patients with insomnia, over
non-active controls [40]. In comparison to meta-
analytical findings investigating disorder-specific effects
of CBT, over non-active controls, our results showed
similar efficacy for depression among depressed partici-
pants [90] and sleep quality among the entire mixed
sample [91].
The efficacy on global symptom severity and under-
lying mechanisms across the sample as well as
disorder-specific efficacy of the current exercise inter-
vention, suggests that exercise might be able treat a
broad range of heterogenous diagnoses with and with-
out comorbidities. Our study results further suggest,
that exercise interventions do not necessarily be tai-
lored to a specific psychiatric disorder referring to ex-
ercise modalities (i.e., type, frequency) to efficaciously
treat disorder-specific symptoms or underlying pro-
cesses across disorders. Rather, exercise modalities,
that have shown therapeutic efficacy among single
psychiatric disorders (i.e., two to three times per
week, for 10 weeks, at a minimum of moderate inten-
sity and a duration of 30 min, partially supervised or
non-supervised, solely aerobic or aerobic combined
with resistance training [33,35,37,43]) seem to be
adoptable to the treatment of heterogenous diagnoses
with and without comorbidities. Similar to the effi-
cacy of transdiagnostic psychological interventions,
this may result in a faster and easier dissemination,
compared to disorder-specific treatments, because
there is no need to learn and apply multiple treat-
ment protocols for different specific disorders [12].
Thus, exercise interventions may improve the existing
treatment gap in mental health care [11] by offering
an efficacious and effective treatment.
Effects on exercise behavior
Study results demonstrated that the current exercise
intervention was highly efficacious in increasing the
amount of exercise, even when participants were not su-
pervised. This is in line with a recent systematic review
[46] and Editorial [48], suggesting that exercise interven-
tions, combined with BCTs, are efficacious in increasing
the amount of exercise. To date, there are only a few ex-
ercise interventions for individuals with psychiatric dis-
orders integrating BCTs [46,85] and only approximately
one quarter of those seem to efficaciously increasing
participants amount of exercise [85]. The frequent fail-
ure to increase exercise behavior among patients with
psychiatric disorders may be related to a lack of motiv-
ation and exercise-related self-regulatory skills (i.e., vol-
ition) in this population [49]. A large proportion of
outpatients in Germany do not exercise on a regular
base [92]. Thus, the integrated BCTs in our intervention
seem to be adequately tailored to outpatients to improve
their deficiencies in motivation and volition regarding
exercise.
Results of our explorative analyses demonstrated a
prediction of symptom reduction by an increase of the
performed amount of exercise, indicating that the
change of exercise might indeed be one specific mode of
action of the therapeutic effects. This moderation effect
is often assumed in the exercise literature, however only
very few trials do report such effects. As far as we know,
only one of the recently published high quality RCTs
[45] did show changes of exercise as the specific mode
of action of the effects of exercise interventions. In
addition to the increase of exercise, results suggest also a
maintenance of exercise behavior because participants
were still exercising even when they were not supervised.
Since there is a lack of follow-up studies of exercise in-
terventions or an absence of measures for exercise be-
havior, little is known about the maintenance of exercise
behavior due to the conduction of exercise interventions
combined or without BCTs [85]. As mentioned in the
introduction, beneficial effects of exercise seem to be
maintained only when exercise behavior has changed
sustainably [45]. Since participants were still exercising
during the non-supervised period of the intervention,
participants might have integrated regular exercise into
their daily life routines. Since the amount of exercise
was assessed 5 weeks and 2 months after the supervised
period, no general conclusions can be drawn about the
long-lasting exercise behavior.
Feasibility of the intervention
Results of this study not only suggest efficacy of the
current exercise intervention but also its feasibility in a
realistic outpatient setting. First, the study sample
included a realistic outpatient sample, waiting for
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psychotherapeutic treatment, with heterogenous, highly
prevalent psychiatric disorders with and without comor-
bid diagnoses. Second, approximately half of the partici-
pants of the intervention group revealed clinically
relevant changes of global symptom severity, compared
to less than one quarter of the control group. Third, the
dropout quote among participants of the intervention
group was low. Additionally, only 5.2% (n= 2) of the
intervention group dropped out due to lost to follow up.
Hence, a strong acceptance and few adherence issues re-
garding the intervention can be assumed. The dropout
rate is similar to prior exercise interventions [38,93] and
lower than other health behaviour change interventions
(e.g., exercise, health education) for individuals with psy-
chiatric disorders, in which the medium average dropout
rate was 45% [94]. The current dropout rate was lower
than those of individual and group CBT interventions (35%).
Most dropouts were reported in outpatient settings [95].
The lower dropout rate in the current exercise intervention
over CBT, might suggest equivalent acceptance of exercise
than CBT among outpatients. Forth, the latency between
pre-treatment assessment and initiation of the intervention
was low, compared to waiting times for psychotherapy of
approximately 5 months in Germany [10]. As stated in the
introduction, prolonged waiting times for treatment are as-
sociated with worsening and chronicity of symptoms and
the development of comorbid diagnoses. Consequently, the
current intervention could be conducted to improve nega-
tive consequences of delayed treatment in Germany. Lastly,
in comparison to an average duration of 19 weeks of prior
exercise intervention for patients with psychiatric disorders
[96], the current exercise intervention was short (12 weeks),
including a very short supervised period of 4 weeks. The
total number of 12 supervised sessions is equivalent to the
average treatment duration of CBT among depressive disor-
ders and anxiety disorders [97,98].
Hence, in addition to the suggested transdiagnostic
and disorder-specific efficacy of the intervention, current
results demonstrated that the exercise intervention
might be feasible treatment among outpatients, that
were waiting for psychotherapeutic treatment in German
health care settings in outpatient units and practices.
Limitations
One limitation of the current study is the use of a pas-
sive control group, which does not allow to control for
non-specific effects of therapy, such as relationship
building or social support. However, the results of our
explorative analyses demonstrated a prediction of symp-
tom reduction by an increase of the performed amount
of exercise, indicating that the change of exercise might
indeed be one specific mode of action of the therapeutic
effects. Second, the measure for global symptom severity
symptoms was comprised of symptoms that were not
characteristic for all included disorders (e.g., aggression).
Therefore, the validity of this metric to assess global
symptom severity among the current sample is disput-
able. However, the GSI is a reliable and valid instrument
to assess clinical global symptom severity across
heterogenous psychiatric disorders and allows to rate
clinically relevant changes of symptomatology [99].
Therefore, the use of this measure was reasonable in this
study because of the inclusion of heterogenous and
highly comorbid psychiatric disorders. Furthermore, the
internationally widespread use of this measure [58] al-
lows to compare study results with international publica-
tions on the effect of various treatments on symptom
severity. Third, eligibility criteria of the current study
allowed for a wide age range. However, participants had
a low average age, which might limit the generalizability
of results to older individuals. Large standard deviations
around the mean value, a large age range (1963 years)
of the current sample as well as a similar average age of
prior exercise trials [36] might increase the generalizability
of results to older individuals. Forth, although the SCID
was conducted at pre-treatment and post-treatment as-
sessment, we did not include results of the SCID from
post-treatment assessment in our analyses. We intended
to assess clinically relevant changes of symptomatology. If
a diagnosis, that was present at pre-treatment assessment,
had still been present at post-treatment assessment, rele-
vant changes on symptomatology would not have been
able to assess. Therefore, we considered self-reported out-
comes (GSI of the SCL-90-R) as a more valid measure to
assess clinically relevant changes of symptomatology.
Moreover, one eligible participant could meet multiple in-
clusion diagnoses. Thus, the comparison of the number of
inclusion diagnoses between pre-treatment and post-
treatment assessment did not seem as a valid indicator of
treatment responders vs. non-responders. Alternative in-
dicators of treatment responders vs. non-responders,
resulting from analyses of the SCID (e.g., counting of
symptom criteria for depressive disorders) seem to be an
arbitrary and not valid approach.
Strengths
First, the high methodological standard is an important
strength of the study. The study involved an RCT design
with stratified block-randomization, which is considered
as the gold standard to evaluate intervention efficacy
[100]. Equal treatment arms and allocation maximized
internal validity [101]. Strict inclusion and exclusion cri-
teria controlled for factors that may obfuscate outcome
measures [102]. Second, the inclusion of a heteroge-
neous sample with a broad age range and various psychi-
atric disorders allowed for a high generalizability of the
results. The conduction of the intervention in a realistic
outpatient setting, the large number of included patients
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with severe, clinically raised symptoms and comorbid
presentations of psychiatric disorders suggest a valid
representation of the clinical reality [12].
Conclusions
In conclusion, our findings suggest the transdiagnostic
efficacy of exercise across heterogenous psychiatric dis-
orders with comparable effects to transdiagnostic psy-
chological interventions. The transdiagnostic efficacy of
the group exercise intervention ImPuls, tailored to and
conducted with heterogenous psychiatric disorders, is
comparable to disorder-specific exercise interventions or
established treatments, such as CBT. The increase of
exercise behavior seemed to be responsible for the thera-
peutic effects of the intervention. The low dropout rate,
the short latency from first meeting to intervention initi-
ation, the small number of supervised sessions, and the
successful increase and maintenance of exercise by
integrating BCTs, may indicate a high feasibility and
acceptance of the current exercise intervention. Due to
the transdiagnostic efficacy and its feasibility within a
real-world outpatient setting, the current exercise inter-
vention may represent a treatment option that could im-
prove the existing treatment gap in the outpatient
mental health care in Germany. Future research is re-
quired to replicate findings with an active control condi-
tion, among older individuals, and additional measures
of global symptom severity. A follow-up study will allow
to assess the maintenance of treatment effects.
Abbreviations
DALYS: Disability-adjusted life years; OCD: Obsessive compulsive disorders;
PTSD: Posttraumatic-stress disorder; ADHD: Attention deficit hyperactivity
disorder; CBT: Cognitive behavioural therapy; RCT: Randomized controlled trial;
BCT: Behaviour change technique; CONSORT: Consolidated Standards of
Reporting Trials; GAF: Global Assessment of Functioning Scale; SCID: Structured
Clinical Interview for DSM-IV (SCID); HASE: Homburg ADHD Scales for Adults;
PSQI: Pittsburgh Sleep Quality Index; GSI: Global Severity Index; SCL-90-
R: Symptom Checklist-90-Revised; BSA questionnaire: Physical Activity, Exercise,
and Sport Questionnaire; SF-B: Sleep Questionnaire B-Revised version;
PSS: Perceived Stress Scale; SF-36: 36-Item Short Form Health Survey; SKK-
Scale: Self Concordance of Sport- and Exercise-related Goals Scale; RPE
Scale: Rating of Perceived Exertion Scale; IBM SPSS: Statistical Package for Social
Science; ITT: Intention-to-treat; MCAR: Missing completely at random
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12888-021-03307-x.
Additional file 1. Characteristics of treatment completers versus
dropouts.
Additional file 2. Sensitivity Analysis using Study Completers.
Additional file 3. Additional Explorative Analyses of the Predictive Value
of Exercise on Primary Outcomes.
Additional file 4. Linear mixed models excluding potential outliers.
Acknowledgements
The authors gratefully acknowledge the psychotherapeutic outpatient clinical of
the department of psychology (especially Marco Daniel Gulewitsch) for helping
recruiting patients, the runnersshop in Tuebingen (Mischa Elbeshausen) for
gifting running shoes for each participant of the IG as well as David Butkiewicus
for proofreading the English Grammar of the article. The authors would also like
to thank Neele Alberts, Luca-Lars Hauser, Ann-Cathrin Werner, Franziska Stock,
Larissa Seyboth, Anna Trusheim, Tim Rohe, Julia Baur, Zuzanna Tkaczynska,
Jonathan Scheef, Sophia Stegmaier, Sonja Hondralis, and Ellen Brölz for serving
as study therapists and/or for their assistance with data collection. We acknow-
ledge support by Open Access Publishing Fund of University of Tübingen.
Authorscontributions
J.-M.Z., B.-A.S., G.S., I.R., M.H. and S.W. contributed to the conception and the
design of the study. J.-M.Z., B.-A.S., M.H., and S.W. completed the acquisition of
data. J.-M.Z., S.W. and I.R. performed the data analysis. J.-M.Z., B.-A.S., G.S., I.R.,
M.H. and S.W. assisted with the interpretation. Original draft preparation was
done by J.-M.Z. and S.W. J.-M.Z., B.-A.S., G.S., I.R., M.H. and S.W. contributed to the
drafting and revision of the final article. J.-M.Z., B.-A.S., G.S., I.R., M.H. and S.W.
have read and agreed to the published version of the manuscript.
Funding
The Robert-Enke Foundation partially funded the study by financing the
compensation for participants of the control group and research assistants.
The funding associations had no involvement in the study design, the collec-
tion, analysis and interpretation of data, in the writing of the report nor in
the decision to submit the article for publication. Open Access funding en-
abled and organized by Projekt DEAL.
Availability of data and materials
The datasets generated and analyzed during the current study are available
in the PsychArchives repository, https://doi.org/10.23668/psycharchives.4625.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of
Helsinki, and approved by the Ethics Committee for psychological research
of the University of Tuebingen, Department of Psychology
(Az_Wolf_2018_0108_99, February 22nd, 2018). Informed consent was
obtained from all subjects involved in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Education & Health Research, Faculty of Economics and
Social Sciences, Institute of Sports Science, University of Tuebingen, 72074
Tuebingen, Germany.
2
Faculty of Medicine, Institute for Clinical Epidemiology
and Applied Biostatistics, University of Tuebingen, 72074 Tuebingen,
Germany.
3
Department of Clinical Psychology and Psychotherapy, Faculty of
Science, Psychological Institute, University of Tuebingen, 72074 Tuebingen,
Germany.
Received: 19 February 2021 Accepted: 20 May 2021
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... This article provides a summary table of clinical studies of exercise therapy for depression or depressive symptoms in recent years, listed in Table 1. Many of the latest studies (18,30,37,38,41,(66)(67)(68)(69) are included. ...
... A summary of clinical studies over the past 3 years on the exercise effects on depression is provided in Table 1. Aerobic exercises (i.e., stride walking, treadmills, cycling, cross trainers) for people with other conditions (schizophrenia, dementia, chronic stroke, at high risk of depression, etc.) (18,66,72,107,(110)(111)(112)(113)(114)(115)(116)(117)(118)(119)(120)(121)(122)(123)(124) and mind-body exercises (i.e., yoga, tai chi, Qigong, Ba-Duan-Jin, Pilates) for people with other conditions (healthy state, menopause, aging, scleroderma, Parkinson's disease, fibromyalgia, HIV, etc.) (37, 39-41, 120, 125-136) were proven to improve depression, anxiety, cognitive function, and overall functions such as sleep quality, psychological well-being, sexual function, and cardiorespiratory fitness as well. Although aerobic exercise and mind-body exercise are the most studied types of exercise with significant results, resistance exercise, stretching exercise, endurance exercise, and other types of exercise have also proven to be effective treatment options for depression (67,72,107,110,(137)(138)(139)(140). ...
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Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles. Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations. Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized. Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18–65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions. Recommendations: Aerobic exercise/mind-body exercise (3–5 sessions per week with moderate intensity lasting for 4–16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.
... Despite the promising evidence for MVAE as an intervention for patients with mental disorders, exercise programs or professional exercise therapy are currently not provided as regular health services within the outpatient mental health care system in Germany. With the aim of combining the current evidence on the efficacy of MVAE and sustained exercise behavior change with specific demands of a real-world outpatient health care setting, ImPuls was developed as a manualized group exercise intervention [47,48] for physically inactive outpatients suffering from major depressive disorders, insomnia, panic disorder with or without agoraphobia and PTSD. ImPuls integrates recent findings about the optimal modalities of exercise for therapeutic efficacy, such as optimal frequency, intensity, time/duration and type of exercise (FITT criteria) for the targeted disorders and evidence regarding sustainable behavior change by integrating behavior change techniques (BCTs). ...
... A recent pilot study evaluating the efficacy of ImPuls within a monocentric randomized controlled trial for patients with major depressive disorders, insomnia, anxiety disorders, PTSD and ADHD showed therapeutic effects comparable to disorder-specific exercise interventions or established treatments, such as CBT [48]. Besides the promising efficacy, the intervention also showed a low drop-out rate (18%) and a large and long-lasting increase of exercise behavior in the intervention group. ...
Article
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Background Mental disorders are prevalent and cause considerable burden of disease. Exercise has been shown to be efficacious to treat major depressive disorders, insomnia, panic disorder with and without agoraphobia and post traumatic stress disorder (PTSD). Methods This pragmatic, two arm, multi-site randomised controlled trial will evaluate the efficacy and cost-effectiveness of the manualized, group-based six-months exercise intervention “ImPuls”, among physically inactive patients with major depressive disorders, insomnia, panic disorder, agoraphobia and PTSD within a naturalistic outpatient context in Germany. A minimum of 375 eligible outpatients from 10 different study sites will be block- randomized to either ImPuls in addition to treatment as usual (TAU) or TAU only. ImPuls will be conducted by trained exercise therapists and delivered in groups of six patients. The program will combine (a) moderate to vigorous aerobic exercise carried out two-three times a week for at least 30 min with (b) behavior change techniques for sustained exercise behavior change. All outcomes will be assessed pre-treatment, post-treatment (six months after randomization) and at follow-up (12 months after randomization). Primary outcome will be self-reported global symptom severity assessed with the Brief Symptom Inventory (BSI-18). Secondary outcomes will be accelerometry-based moderate to vigorous physical activity, self-reported exercise, disorder-specific symptoms, quality-adjusted life years (QALY) and healthcare costs. Intention-to-treat analyses will be conducted using mixed models. Cost-effectiveness and cost-utility analysis will be conducted using incremental cost-effectiveness and cost-utility ratios. Discussion Despite its promising therapeutic effects, exercise programs are currently not provided within the outpatient mental health care system in Germany. This trial will inform service providers and policy makers about the efficacy and cost-effectiveness of the group-based exercise intervention ImPuls within a naturalistic outpatient health care setting. Group-based exercise interventions might provide an option to close the treatment gap within outpatient mental health care settings. Trial registration The study was registered in the German Clinical Trials Register (ID: DRKS00024152 , 05/02/2021).
... En la Tabla II, se presentan los principales resultados en esas categorías, se incluyen sólo ar-tículos publicados en 2021 y 2022 y que contengan todos los términos de la búsqueda ¨psicoterapia basada en evidencia AND tratamientos combinados AND severidad comorbili-dad¨. Se observa que tanto en grandes poblaciones (Zeibig et al., 2021), como en estudios de caso único (Kato et al., 2021), se impone la necesidad de superar el esquema de clasificación de diagnóstico específico, por uno que aborde la complejidad y comorbilidad de los síntomas psi-Tabla 2. Unidades de Análisis Intervenciones psicológicas y/o combinadas, basadas en evidencias con pacientes con severidad y comorbilidad quiátricos y la personalización del tratamiento (Deif y Salama, 2021). Para el caso de las Depre-siones Resistentes al Tratamiento, dada su prevalencia y altos costos para el Sistema de Salud, inclusive se plantea una nueva forma de clasificación nosológica que incluya las complejidades que conllevan los trastornos psiquiátricos resistentes, a fin de abordad mejor su comprensión y tratamiento (Rush et al., 2022). ...
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Full-text available
Systematic Revision on Effective combined treatments for patients with severity and comorbidity
... In adults with BD, physical activity interventions have been found to be feasible and acceptable, as reflected by retention in the intervention and completion of study measures (Sylvia et al., 2013b, Sylvia et al., 2013bThomson et al., 2015), and can produce significant improvements in physical activity, depression symptoms, medical comorbidities, and global functioning (Ng, Dodd, & Berk, 2007;Sylvia, Salcedo, et al., 2013). More recently, a 12-week behavior change intervention with moderate-vigorous aerobic exercise was found to improve psychiatric symptoms, sleep, and increase frequency of exercise in a transdiagnostic (depressive disorders, anxiety disorders, insomnia, and attention-deficit/hyperactivity disorders) adult sample (Zeibig et al., 2021). Studies of youth with depression have also shown that significant improvements in exercise frequency and CRF, along with improvements in depression and functioning, can be achieved in 8-12 weeks (Hughes et al., 2013;Nabkasorn et al., 2006;Nasstasia et al., 2019). ...
Article
Objectives Bipolar disorder (BD) is associated with decreased cardiorespiratory fitness (CRF) and exercise. Despite the potential benefits for physical and mental health, there is a gap in knowledge regarding treatments targeting improved CRF for BD. This treatment development and feasibility study sought to bridge the knowledge-to-action gap in this area. Methods Twenty youth with BD, 18.0 ± 2.3 years old, enrolled in an exercise behavior change counselling (BCC) intervention targeting improved CRF. The 12-week active intervention included four in-person sessions, augmented by phone/texting sessions on intervening weeks. Optional modules included exercise coaching, family involvement, and peer support. Booster phone/texting sessions occurred at weeks 16 and 20. Participants completed CRF testing at weeks 0, 2, 8, 12, and 24. Results Seventy percent of participants (14/20) completed all study visits and measures. In the overall enrolled sample, 82% of CRF tests were completed (range 0–5 of 5). There were no significant changes in subjective (via self-report) and objective (via Fitbit) measures of physical activity or in CRF, though CRF testing was consistently associated with active post-exercise improvement in mood. Most participants reported being very satisfied with the intervention following the 12-week active intervention (13/14) and at week 24 (12/14). Therapist fidelity to the BCC manual was high. Conclusion Good attendance and study adherence provides preliminary evidence of the feasibility and acceptability of a behavioral intervention targeting CRF in youth with BD. Future studies refining the current intervention are warranted toward a goal of demonstrating improved CRF in a randomized controlled trial.
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Full-text available
Background This systematic review and meta-analysis assesses the efficacy of regular, moderate to vigorous physical activity (MVPA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents in randomized controlled trials (RCTs). Methods RCTs including children and adolescents with clinically diagnosed ADHD, implementing regular MVPA, and assessing ADHD core-symptoms on a valid rating scale post-intervention (primary outcome) were included. Outcomes were pooled through random-effects meta-analysis. Prospero registration: CRD42019142166. Results MVPA had a small effect on total ADHD core symptoms ( n = 11; g = −0.33; 95% CI [−0.63; −0.02]; p = .037). Conclusions MVPA could serve as an alternative treatment for ADHD. New RCTs are necessary to increase the understanding of the effect regarding frequency, intensity, type of MVPA interventions, and differential effects on age groups.
Article
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Despite a longstanding and widespread influence of the diagnostic approach to mental ill health, there is an emerging and growing consensus that such psychiatric nosologies may no longer be fit for purpose in research and clinical practice. In their place, there is gathering support for a "transdiagnostic" approach that cuts across traditional diagnostic boundaries or, more radically, sets them aside altogether, to provide novel insights into how we might understand mental health difficulties. Removing the distinctions between proposed psychiatric taxa at the level of classification opens up new ways of classifying mental health problems, suggests alternative conceptualizations of the processes implicated in mental health, and provides a platform for novel ways of thinking about onset, maintenance, and clinical treatment and recovery from experiences of disabling mental distress. In this Introduction to a Special Section on Transdiagnostic Approaches to Psychopathology, we provide a narrative review of the transdiagnostic literature in order to situate the Special Section articles in context. We begin with a brief history of the diagnostic approach and outline several challenges it currently faces that arguably limit its applicability in current mental health science and practice. We then review several recent transdiagnostic approaches to classification, biopsychosocial processes, and clinical interventions, highlighting promising novel developments. Finally, we present some key challenges facing transdiagnostic science and make suggestions for a way forward. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Article
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Background: Attention-deficit/hyperactivity disorder (ADHD) is linked to high levels of perceived stress in adult populations. Thus, it is not surprising that stress managing techniques are being included in treatment protocols for adults with ADHD. There is, however, a paucity of studies on perceived stress in adolescents with ADHD. Aims: This study aims to explore how adolescents with ADHD perceive and experience stress (and stressors) using a qualitative approach. Methods: Explorative interviews were conducted with 20 adolescents (Mean age: 16.30) diagnosed with ADHD in conjunction with group treatment therapy. Data were analysed using qualitative content analysis. Results: Stress and ADHD, as well as stress, anxiety and ill-health, were described as closely intertwined. The result is presented in four categories: stress is often present, triggers of stress, stress affects daily life, and stress can be handled and prevented. A relation was found between stress and feelings of helplessness, ill-health and anxiety. Stress was viewed as being out of proportion with reality and was driven by such factors as ADHD symptoms, school demands, unpredictable situations and relational problems. Several negative consequences of stress were reported, including postponing schoolwork and the tendency to give up. Some participants also reported performing better when stressed. Accepting help from others, practising acceptance, settling down and controlling oneself, and planning in advance were seen as helpful stress managing techniques. Conclusions: Stress should be considered among other problems related to ADHD. Psychoeducation about stress, stress managing techniques and coaching should be included in the treatment of adolescents with ADHD.
Article
Full-text available
Background Exercise may improve neuropsychiatric and cognitive symptoms in people with mental disorders, but the totality of the evidence is unclear. We conducted a meta-review of exercise in (1) serious mental illness (schizophrenia spectrum, bipolar disorder and major depression (MDD)); (2) anxiety and stress disorders; (3) alcohol and substance use disorders; (4) eating disorders (anorexia nervosa bulimia nervosa, binge eating disorders, and (5) other mental disorders (including ADHD, pre/post-natal depression). Methods Systematic searches of major databases from inception until 1/10/2018 were undertaken to identify meta-analyses of randomised controlled trials (RCTs) of exercise in people with clinically diagnosed mental disorders. In the absence of available meta-analyses for a mental disorder, we identified systematic reviews of exercise interventions in people with elevated mental health symptoms that included non-RCTs. Meta-analysis quality was assessed with the AMSTAR/+. Results Overall, we identified 27 systematic reviews (including 16 meta-analyses representing 152 RCTs). Among those with MDD, we found consistent evidence (meta-analyses = 8) that exercise reduced depression in children, adults and older adults. Evidence also indicates that exercise was more effective than control conditions in reducing anxiety symptoms (meta-analyses = 3), and as an adjunctive treatment for reducing positive and negative symptoms of schizophrenia (meta-analyses = 2). Regarding neurocognitive effects, exercise improved global cognition in schizophrenia (meta-analyses = 1), children with ADHD (meta-analyses = 1), but not in MDD (meta-analyses = 1). Among those with elevated symptoms, positive mental health benefits were observed for exercise in people with pre/post-natal depression, anorexia nervosa/bulimia nervosa, binge eating disorder, post-traumatic stress disorder and alcohol use disorders/substance use disorders. Adverse events were sparsely reported. Conclusion Our panoramic meta-overview suggests that exercise can be an effective adjunctive treatment for improving symptoms across a broad range of mental disorders.
Article
Full-text available
Background: The present study meta-analytically reviewed the effects of exercise on four transdiagnostic treatment targets: anxiety sensitivity (AS), distress tolerance (DT), stress reactivity (SR), and general self-efficacy (GSE). Methods: We conducted systematic searches of peer-reviewed studies in bibliographical databases (Cochrane Library, psychINFO, PubMed) before April 1, 2018. Only randomized controlled trials (RCT) evaluating the effect of exercise on AS, DT, SR, or GSE using at least one validated outcome instrument in a sample of adolescents (≥13 years old) or adults were selected. We employed a meta-analysis of effects using random-effects pooling modeling for each treatment target. Results: The systematic search yielded 28 RCTs meeting eligibility criteria. Exercise interventions had a large effect on reducing AS (six studies, Hedges's g = 0.72, p = .001), a medium effect on increasing GSE (eight studies, Hedges's g = 0.59, p < .001), and a small effect on reducing SR (ten studies, Hedges's g = 0.32, p < .001). Evidence from four studies suggested that exercise interventions had a small but non-significant effect on increasing DT (Hedges's g = 0.21, p = .26). Conclusions: This meta-analysis provides preliminary evidence exercise can engage certain transdiagnostic targets. Further research is required to optimize exercise intervention parameters to achieve the strongest effects on these important mechanistic variables.
Book
Dieses Buch ist ein Plädoyer für Gruppenangebote in der ambulanten psychotherapeutischen Praxis. Es versammelt Grundlagen, Erfahrungen und Praxistipps für Gruppen in verschiedenen Settings, Patientengruppen und Therapieschulen und leistet einen Beitrag zur Debatte um die patientenorientierte Versorgung. Psychologische und ärztliche Psychotherapeuten sowie Psychiater erfahren, wie sie Gruppenpsychotherapie nach den Richtlinienverfahren für ihre ambulante Praxis neu entdecken, gestalten und ausbauen können. Gruppenpsychotherapien erlauben eine lebendige, bereichernde und ökonomische Anwendung von Psychotherapie bei einer Vielzahl von Problemfeldern und Störungen und sind im Hinblick auf ihre Wirksamkeit sehr gut abgesichert. Aus dem Inhalt Psychodynamische Psychotherapie in Gruppen – Verhaltenstherapie in Gruppen – Kinder- und Jugendlichenpsychotherapie in Gruppen – Kombination von Einzel- und Gruppenpsychotherapie – Gruppenpsychotherapie in der ambulanten Rehabilitation – Praxisorganisation und Abrechnung – Stand der Forschung. Die Herausgeber Dr. med. Dankwart Mattke ist in fachärztlicher Praxis tätig: psychosomatische Medizin, Psychiatrie, Neurologie, Psychotherapie, Psychoanalyse; zudem in eigener Beratungssozietät: Supervision, Coaching, Training, Organisations- und Teamentwicklung. Dipl.-Psych., Dipl.-Theol. Martin Pröstler ist Psychoanalytiker und Gruppenlehranalytiker, niedergelassen als Psychotherapeut, Supervisor und Organisationsberater in eigener Praxis.
Article
Objective: Despite a vast evidence-base advocating the psychological benefits of physical activity, relatively little is understood about how combining physical activity with psychological therapies may influence these positive effects. The aim of this paper is to systematically analyse evidence from studies adopting a combined approach, and identify potential mechanisms of action on clinical outcomes. Methods: The Embase, PsycINFO and Medline (PubMed and OVID) databases were searched for applicable trials published up to December 2018. Relevant data was extracted from eligible studies, and the Effective Public Health Practice Project (EPHPP) tool was utilised to objectively assess the quality of each study. Results: Twenty-two studies met the inclusion criteria, seven of which were rated as methodologically `strong'. Combining physical activity with psychological therapy consistently engendered positive effects on outcomes compared with treatment as usual. Similar improvements in psychological outcomes were observed in most (7/8) groups receiving physical activity alone. Increased levels of physical activity were observed in psychologically-informed interventions, however this effect was unrelated to changes in psychological outcomes. Limitations: Clinical and methodological heterogeneity precluded meta-analyses of results, while risk of bias detected in the studies may compromise overall validity of the findings. Conclusions: Physical activity interventions may be a viable alternative to psychological therapies, provided psychological approaches are incorporated into the implementation design (i.e. behavioural activation). Improved psychological outcomes may be observed regardless of `dose' received, however further research is required to ascertain whether psychosocial mechanisms of change mediate positive effects.
Article
People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. Physical-health disparities are observed across all mental illnesses in all countries. The high rate of physical comorbidity, which often has poor clinical management, reduces life expectancy for people with mental illness, and increases the personal, social, and economic cost of mental illness across the lifespan. This Commission summarises advances in understanding on the topic of physical health in people with mental illness, and presents clear directions for health promotion, clinical care, and future research. It aims to: (1) Establish highly pertinent aspects of physical health-related morbidity and mortality that have transdiagnostic applications; (2) Highlight the common modifiable factors that drive disparities in physical health; (3) Present actions and initiatives for health policy and clinical services to address these issues; and (4) Identify promising areas for future research that could identify novel solutions.
Article
Background and objectives: The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). Methods: Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance. Results: All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT. Limitations: Results are based on retrospective self-reports, which might restrict validity of the measurements. Conclusions: Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.