Sports Medicine

, Volume 47, Issue 2, pp 343–352 | Cite as

Cardiorespiratory Fitness in Severe Mental Illness: A Systematic Review and Meta-analysis

  • Davy VancampfortEmail author
  • Simon Rosenbaum
  • Felipe Schuch
  • Philip B. Ward
  • Justin Richards
  • James Mugisha
  • Michel Probst
  • Brendon Stubbs
Systematic Review



Cardiorespiratory fitness (CRF) among people with severe mental illness (SMI) (i.e., schizophrenia, bipolar disorder, and major depressive disorder) is a critical clinical risk factor given its relationship to cardiovascular disease and premature mortality.


This study aimed to: (1) investigate the mean CRF in people with SMI versus healthy controls; (2) explore moderators of CRF; and (3) investigate whether CRF improved with exercise interventions and establish if fitness improves more than body mass index following exercise interventions.


Major electronic databases were searched systematically. A meta-analysis calculating Hedges’ g statistic was undertaken.


Across 23 eligible studies, pooled mean CRF was 28.7 mL/kg/min [95 % confidence interval (CI) 27.3 to 30.0 mL/kg/min, p < 0.001, n = 980]. People with SMI had significantly lower CRF compared with controls (n = 310) (Hedges’ g = −1.01, 95 % CI −1.18 to −0.85, p < 0.001). There were no differences between diagnostic subgroups. In a multivariate regression, first-episode (β = 6.6, 95 % CI 0.6–12.6) and inpatient (β = 5.3, 95 % CI 1.6–9.0) status were significant predictors of higher CRF. Exercise improved CRF (Hedges’ g = 0.33, 95 % CI = 0.21–0.45, p = 0.001), but did not reduce body mass index. Higher CRF improvements were observed following interventions at high intensity, with higher frequency (at least three times per week) and supervised by qualified personnel (i.e., physiotherapists and exercise physiologists).


The multidisciplinary treatment of people with SMI should include a focus on improving fitness to reduce all-cause mortality. Qualified healthcare professionals supporting people with SMI in maintaining an active lifestyle should be included as part of multidisciplinary teams in mental health treatment.


Bipolar Disorder Major Depressive Disorder Aerobic Exercise Exercise Intervention Severe Mental Illness 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with Ethical Standards


Davy Vancampfort has support from the Research Foundation-Flanders (FWOVlaanderen). Brendon Stubbs was supported by the Collaboration for Leadership in Applied Health Research and Care South London for this article. No other sources of funding were used to assist in the preparation of this article.

Conflict of interest

Davy Vancampfort, Simon Rosenbaum, Felipe Schuch, Philip Ward, Justin Richards, James Mugisha, Michel Probst, and Brendon Stubbs declare that they have no conflicts of interest relevant to the content of this review.

Supplementary material

40279_2016_574_MOESM1_ESM.docx (24 kb)
Supplementary material 1 (DOCX 23 kb)


  1. 1.
    Reininghaus U, Dutta R, Dazzan P, et al. Mortality in schizophrenia and other psychoses: a 10-year follow-up of the ÆSOP first-episode cohort. Schizophr Bull. 2015;41(3):664–73.CrossRefPubMedGoogle Scholar
  2. 2.
    Osborn DP, Levy G, Nazareth I, et al. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s General Practice Research Database. Arch Gen Psychiatry. 2007;64(2):242–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Lawrence D. Excess mortality, mental illness and global burden of disease. Epidemiol Psychiatr Sci. 2015;24(2):141–3.CrossRefPubMedGoogle Scholar
  4. 4.
    Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64(10):1123–31.CrossRefPubMedGoogle Scholar
  5. 5.
    Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72(4):334–41.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ellingrod VL, Taylor SF, Dalack G, et al. Risk factors associated with metabolic syndrome in bipolar and schizophrenia subjects treated with antipsychotics: the role of folate pharmacogenetics. J Clin Psychopharmacol. 2012;32(2):261.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Manu P, Correll CU, Wampers M, et al. Markers of inflammation in schizophrenia: association vs. causation. World Psychiatry. 2014;13(2):189–92.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Vancampfort D, Stubbs B, Mitchell AJ, et al. Risk of metabolic syndrome and its components in people with schizophrenia, bipolar and major depressive disorders: a large scale meta-analysis of 198 studies. World Psychiatry. 2015;14(3):339–47.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301(19):2024–35.CrossRefPubMedGoogle Scholar
  10. 10.
    Barry VW, Baruth M, Beets MW, et al. Fitness vs. fatness on all-cause mortality: a meta-analysis. Progr Cardiovasc Dis. 2014;56(4):382–90.CrossRefGoogle Scholar
  11. 11.
    Lee DC, Artero EG, Sui X, et al. Review: mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol. 2010;24(4 Suppl):27–35.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kimhy D, Vakhrusheva J, Bartels MN, et al. Aerobic fitness and body mass index in individuals with schizophrenia: implications for neurocognition and daily functioning. Psychiatry Res. 2014;220(3):784–91.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Rosenbaum S, Tiedemann A, Sherrington C, et al. Physical activity interventions for people with mental illness: a systematic review and meta-analysis. J Clin Psychiatry. 2014;75(9):964–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Bartels SJ, Pratt SI, Aschbrenner KA, et al. Pragmatic replication trial of health promotion coaching for obesity in serious mental illness and maintenance of outcomes. Am J Psychiatry. 2014;172(4):344–52.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Chwastiak L. Making evidence-based lifestyle modification programs available in community mental health centers: why so slow? J Clin Psychiatry. 2015;76(4):519–20.CrossRefGoogle Scholar
  16. 16.
    Vancampfort D, Rosenbaum S, Probst M, et al. Promotion of cardiorespiratory fitness in schizophrenia: a clinical overview and meta-analysis. Acta Psychiatr Scand. 2015;132(2):131–43.CrossRefPubMedGoogle Scholar
  17. 17.
    Ward MC, White DT, Druss BG. A meta-review of lifestyle interventions for cardiovascular risk factors in the general medical population: lessons for individuals with serious mental illness. J Clin Psychiatry. 2015;76(4):477–86.CrossRefGoogle Scholar
  18. 18.
    Firth J, Cotter J, Elliott R, et al. A systematic review and meta-analysis of exercise interventions in schizophrenia patients. Psychol Med. 2015;45(7):1343–61.CrossRefPubMedGoogle Scholar
  19. 19.
    Vancampfort D, Rosenbaum S, Ward PB, et al. Exercise improves cardiorespiratory fitness in people with schizophrenia: a systematic review and meta-analysis. Schizophr Res. 2015;169(1–3):453–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Stubbs B, Rosenbaum S, Vancampfort D, et al. Exercise improves cardiorespiratory fitness in people with depression: a meta-analysis of randomized control trials. J Affect Disord. 2016;190:249–53.CrossRefPubMedGoogle Scholar
  21. 21.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA. 2000;283(15):2008–12.CrossRefPubMedGoogle Scholar
  22. 22.
    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. PLoS Med. 2009;6(7):e1000097.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM 5). Washington, DC: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  24. 24.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). Washington, DC: American Psychiatric Association; 1994.Google Scholar
  25. 25.
    World Health Organization. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization; 1993.Google Scholar
  26. 26.
    Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Publ Health Rep. 1985;100(2):126.Google Scholar
  27. 27.
    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.CrossRefPubMedGoogle Scholar
  28. 28.
    Knubben K, Reischies FM, Adli M, et al. A randomised, controlled study on the effects of a short-term endurance training programme in patients with major depression. Br J Sports Med. 2007;41(1):29–33.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Krogh J, Saltin B, Gluud C, et al. The DEMO trial: a randomized, parallel-group, observer-blinded clinical trial of strength versus aerobic versus relaxation training for patients with mild to moderate depression. J Clin Psychiatry. 2009;70(6):790–800.CrossRefPubMedGoogle Scholar
  30. 30.
    Pajonk FG, Wobrock T, Gruber O, et al. Hippocampal plasticity in response to exercise in schizophrenia. Arch Gen Psychiatry. 2010;67(2):133–43.CrossRefPubMedGoogle Scholar
  31. 31.
    Heggelund J, Nilsberg GE, Hoff J, et al. Effects of high aerobic intensity training in patients with schizophrenia: a controlled trial. Nord J Psychiatry. 2011;65(4):269–75.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Strassnig M, Brar JS, Ganguli R. Low cardiorespiratory fitness and physical functional capacity in obese patients with schizophrenia. Schizophr Res. 2011;126(1):103–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Krogh J, Videbech P, Thomsen C, et al. DEMO-II trial. Aerobic exercise versus stretching exercise in patients with major depression: a randomised clinical trial. PLoS One. 2012;7(10):e48316.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Nilsson BM, Olsson RM, Öman A, et al. Physical capacity, respiratory quotient and energy expenditure during exercise in male patients with schizophrenia compared with healthy controls. Eur Psychiatry. 2012;27(3):206–12.CrossRefPubMedGoogle Scholar
  35. 35.
    Scheewe TW, Takken T, Kahn RS, et al. Effects of exercise therapy on cardiorespiratory fitness in patients with schizophrenia. Med Sci Sports Exerc. 2012;44(10):1834–42.CrossRefPubMedGoogle Scholar
  36. 36.
    Strassnig MT, Newcomer JW, Harvey PD. Exercise improves physical capacity in obese patients with schizophrenia: pilot study. Schizophr Res. 2012;141(2):284–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Ostermann S, Herbsleb M, Schulz S, et al. Exercise reveals the interrelation of physical fitness, inflammatory response, psychopathology, and autonomic function in patients with schizophrenia. Schizophr Bull. 2012;39(5):1139.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Abdel-Baki A, Brazzini-Poisson V, Marois F, et al. Effects of aerobic interval training on metabolic complications and cardiorespiratory fitness in young adults with psychotic disorders: a pilot study. Schizophr Res. 2013;149(1–3):112–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Bredin SS, Warburton DE, Lang DJ. The health benefits and challenges of exercise training in persons living with schizophrenia: a pilot study. Brain Sci. 2013;3(2):821–48.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Ozbulut O, Genc A, Bagcioglu E, et al. Evaluation of physical fitness parameters in patients with schizophrenia. Psychiatry Res. 2013;210(3):806–11.CrossRefPubMedGoogle Scholar
  41. 41.
    Kimhy D, Vakhrusheva J, Bartels MN, et al. Aerobic fitness and body mass index in individuals with schizophrenia: implications for neurocognition and daily functioning. Psychiatry Res. 2014;220(3):784–91.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Kimhy D, Vakhrusheva J, Bartels MN, et al. The impact of aerobic exercise on brain-derived neurotrophic factor and neurocognition in individuals with schizophrenia: a single-blind, randomized clinical trial. Schizophr Bull. 2015;41(4):859–68.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Leone M, Lalande D, Thériault L, et al. Impact of an exercise program on the physiologic, biologic and psychologic profiles in patients with schizophrenia. Schizophr Res. 2015;164(1–3):270.CrossRefPubMedGoogle Scholar
  44. 44.
    Nyboe L, Vestergaard CH, Lund H, et al. Metabolic syndrome in first-time hospitalized patients with depression: a 1-year follow-up study. Acta Psychiatr Scand. 2016;133(3):241–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Rosenbaum S, Lagopoulos J, Curtis J, et al. Aerobic exercise intervention in young people with schizophrenia spectrum disorders; improved fitness with no change in hippocampal volume. Psychiatry Res Neuroimaging. 2015;232(2):200–1.CrossRefPubMedGoogle Scholar
  46. 46.
    Schuch FB, Vasconcelos-Moreno MP, Borowsky C, et al. Exercise and severe major depression: effect on symptom severity and quality of life at discharge in an inpatient cohort. J Psychiatr Res. 2015;61:25–32.CrossRefPubMedGoogle Scholar
  47. 47.
    Schuch FB, da Silveira LE, de Zeni TC, et al. Effects of a single bout of maximal aerobic exercise on BDNF in bipolar disorder: a gender-based response. Psychiatry Res. 2015;229(1):57–62.CrossRefPubMedGoogle Scholar
  48. 48.
    Vancampfort D, Guelinkcx H, Probst M, et al. Associations between metabolic and aerobic fitness parameters in patients with schizophrenia. J Nerv Ment Dis. 2015;203(1):23–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Vancampfort D, Buys R, Sienaert P, et al. Validity of the 6 min walk test in outpatients with bipolar disorder. Psychiatry Res. 2015;230(2):664–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Kerling A, Tegtbur U, Gützlaff E, et al. Effects of adjunctive exercise on physiological and psychological parameters in depression: a randomized pilot trial. J Affect Disord. 2015;177:1–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Daumit GL, Dickerson FB, Wang NY, et al. A behavioral weight-loss intervention in persons with serious mental illness. N Engl J Med. 2013;368(17):1594–602.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Green CA, Yarborough BJH, Leo MC, et al. Weight maintenance following the STRIDE lifestyle intervention for individuals taking antipsychotic medications. Obesity. 2015;23(10):1995–2001.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Church TS, LaMonte MJ, Barlow CE, et al. Cardiorespiratory fitness and body mass index as predictors of cardiovascular disease mortality among men with diabetes. Arch Intern Med. 2005;165(18):2114–20.CrossRefPubMedGoogle Scholar
  54. 54.
    Hainer V, Toplak H, Stich V. Fat or fit: what is more important? Diabetes Care. 2009;32(Suppl 2):S392–7.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Parker BA, Kalasky MJ, Proctor DN. Evidence for sex differences in cardiovascular aging and adaptive responses to physical activity. Eur J Appl Physiol. 2010;110(2):235–46.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Swift DL, Staiano AE, Johannsen NM, et al. Low cardiorespiratory fitness in African Americans: a health disparity risk factor? Sports Med. 2013;43(12):1301–13.CrossRefPubMedGoogle Scholar
  57. 57.
    Richardson LD, Norris M. Access to health and health care: how race and ethnicity matter. Mt Sinai J Med. 2010;77(2):166–77.CrossRefPubMedGoogle Scholar
  58. 58.
    Curtis J, Watkins A, Rosenbaum S, et al. Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic-induced weight gain in first-episode psychosis. Early Interv Psychiatry. 2016;10(3):267–76.CrossRefPubMedGoogle Scholar
  59. 59.
    Soundy A, Freeman P, Stubbs B, et al. The transcending benefits of physical activity for individuals with schizophrenia: a systematic review and meta-ethnography. Psychiatry Res. 2014;220(1):11–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Gross J, Vancampfort D, Stubbs B, et al. A narrative synthesis investigating the use and value of social support to promote physical activity among individuals with schizophrenia. Disabil Rehabil. 2016;38(2):123–50.CrossRefPubMedGoogle Scholar
  61. 61.
    Vancampfort D, Rosenbaum S, Probst M, et al. What are the top 10 physical activity research questions in schizophrenia? Disabil Rehabil. 2016;1–9.Google Scholar
  62. 62.
    Vancampfort D, Stubbs B, Ward P, et al. Integrating physical activity as medicine in the care of people with severe mental illness. Aust N Z J Psychiatry. 2015;49(8):681–2.CrossRefPubMedGoogle Scholar
  63. 63.
    Vancampfort D, Stubbs B, Ward PB, et al. Why moving more should be promoted for severe mental illness. Lancet Psychiatry. 2015;2(4):295.CrossRefPubMedGoogle Scholar
  64. 64.
    Weston KS, Wisløff U, Coombes JS. High-intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br J Sports Med. 2014;48(16):1227–34.CrossRefPubMedGoogle Scholar
  65. 65.
    Vancampfort D, Stubbs B, Venigalla SK, et al. Adopting and maintaining physical activity behaviours in people with severe mental illness: the importance of autonomous motivation. Prev Med. 2015;81:216–20.CrossRefPubMedGoogle Scholar
  66. 66.
    Beauchamp MK, Nonoyama M, Goldstein RS, et al. Interval versus continuous training in individuals with chronic obstructive pulmonary disease—a systematic review. Thorax. 2010;65(2):157–64.CrossRefPubMedGoogle Scholar
  67. 67.
    Vancampfort D, Probst M, Sweers K, et al. Relationships between obesity, functional exercise capacity, physical activity participation and physical self-perception in people with schizophrenia. Acta Psychiatr Scand. 2011;123(6):423–30.CrossRefPubMedGoogle Scholar
  68. 68.
    Biddle SJ, Batterham AM. High-intensity interval exercise training for public health: a big HIT or shall we HIT it on the head? Int J Behav Nutr Phys Act. 2015;12(1):95.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Mitchell A, De Hert M. Promotion of physical health in persons with schizophrenia: can we prevent cardiometabolic problems before they begin? Acta Psychiatr Scand. 2015;132(2):83–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Davy Vancampfort
    • 1
    • 2
    Email author
  • Simon Rosenbaum
    • 3
  • Felipe Schuch
    • 4
    • 5
  • Philip B. Ward
    • 3
  • Justin Richards
    • 6
  • James Mugisha
    • 7
  • Michel Probst
    • 1
  • Brendon Stubbs
    • 8
    • 9
  1. 1.Department of Rehabilitation SciencesKU Leuven-University of LeuvenLeuvenBelgium
  2. 2.KU Leuven-University of Leuven, University Psychiatric CentreKortenbergBelgium
  3. 3.School of PsychiatryUniversity of New South WalesSydneyAustralia
  4. 4.Hospital de Clinicas de Porto AlegrePorto AlegreBrazil
  5. 5.Programa de Pos Graduacaoem Ciencias Medicas: PsiquiatriaUniversidade Federal do Rio Grande do SulPorto AlegreBrazil
  6. 6.School of Public Health and Charles Perkins CentreUniversity of SydneySydneyAustralia
  7. 7.Butabika National Referral and Mental Health HospitalKampalaUganda
  8. 8.Physiotherapy DepartmentSouth London and Maudsley NHS Foundation TrustLondonUK
  9. 9.Health Service and Population Research Department, Institute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK

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