A cognitive intervention to increase physical activity in people with schizophrenia

Background NHS England (2018) highlight that 'People living with severe mental illness (SMI) face one of the greatest health inequality gaps in England.

The life expectancy for people with SMI is 15-20-years lower than the general population.' One common, and potentially tractable, reason for poor physical health is reduced physical activity. People with schizophrenia 1) take less exercise and 2) sit more in the daytime (11 hours per day).

These types of inactivity are - independently - detrimental to physical health (e.g. metabolic disorders, cardiovascular and respiratory disease) and mental health (e.g. depression and symptoms of schizophrenia).

A number of previous interventions targeting physical activity in people with schizophrenia have had limited efficacy, low adherence, and high attrition.

There are three key reasons: 1) failure to address significant psychological barriers 2) failure to address sedentary behaviour and 3) top down design and delivery of interventions. These will be directly addressed in the design of a new intervention.

First, three key psychological barriers (depression, fear, and low motivation) will be directly addressed using a cognitive approach that underpins the most efficacious psychological treatments.

The approach highlights direct experiential learning, and this will be amplified by the use of immersive virtual reality. Second, sedentary behaviour will be targeted in its own right. Third, the intervention will be co-designed with people who have lived experience, carers, and healthcare workers.

Research aim The overall research aim is to produce a highly engaging, accessible, and scalable physical activity intervention for people with schizophrenia that doubles standing time and increases time spent exercising by 30%.

Plan of investigation The investigation will comprise three phases: a qualitative investigation, a co-design process, and a proof-of-principle study.

Phase One will be a qualitative study using thematic analysis to analyse data from focus groups and individual interviews. This will explore barriers and facilitators of being more physically active and less sedentary.

Patients with lived experience of schizophrenia (both who have and who have not increased physical activity), carers, and healthcare professionals will participate.

Phase Two will be the co-design of the intervention by people with lived experience, their carers, healthcare providers, and the researcher.

A small co-design team (n=10) will use psychological theory alongside the insights from the literature and the qualitative study to operationalise the intervention. There will be clear parameters set for the intervention.

An iterative process will allow a broader group (n = 24) to contribute, ensuring the intervention is engaging and accessible.

Phase Three will be a proof of principle test of the intervention, using single case experimental design with 15 patients. Actigraphy will be used to measure exercise and sedentary behaviour before, during, and after the intervention. Changes in the psychological barriers will also be assessed. There are pre-specified success criteria, which will inform the design of a future definitive trial.

Outputs The research will produce an acceptable, accessible, and potentially effective novel intervention to increase physical activity. Future work would need to test this in a randomised controlled trial.