45 - Beebe2005

Issues in Mental Health Nursing, 26:661–676, 2005
Copyright c Taylor & Francis Inc.

ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.1080/01612840590959551
EFFECTS OF EXERCISE ON MENTAL

AND PHYSICAL HEALTH PARAMETERS
OF PERSONS WITH SCHIZOPHRENIA
Issues Ment Health Nurs Downloaded from informahealthcare.com by Clemson University on 06/04/14
Lora Humphrey Beebe, PhD, RN

Lili Tian, PhD
Nancy Morris, BSN
Ann Goodwin, MSN
Staccie Swant Allen, BSN, EMT-P
John Kuldau, MD
University of Florida, College of Nursing, Gainesville,
Florida, USA
Although the benefits of exercise are well documented, few

For personal use only.
published research studies have examined exercise in

persons with schizophrenia. This pilot examined a 16-week
walking program for outpatients diagnosed with
schizophrenia (N = 10). Six-minute walking distance, body
mass index, percent body fat and severity of psychiatric
symptoms were measured. Experimental participants in the
walking group experienced significant reductions in body
fat (p = 0.03) compared to a control group not participating
in the exercises during the same time period. Experimental
participants also had greater aerobic fitness, lower body
mass indexes, and fewer psychiatric symptoms than controls
at the conclusion of the program. Research is needed to
identify effective exercise interventions and feasible delivery
modalities for persons with schizophrenia in community
settings.
Persons with schizophrenia face many challenges in maintaining their

physical health. Their death rates from obesity-related diseases, diabetes,
and respiratory and cardiovascular diseases are significantly higher than
those of the general population (Harris & Barraclough, 1998). The
most effective medications for managing their psychiatric disease (i.e.,
Address correspondence to Lora Humphrey Beebe, University of Florida, College of Nursing,

P.O. Box 100187, Gainesville, FL 32610-0187. E-mail: lbeebe@ufl.edu
661
662 L. H. Beebe et al.
atypicals such as Clozaril and Zyprexa) are associated with weight gain,
glucose dysregulation and diabetes (Allison et al., 1999; Golf & Shader,
1995; Henderson et al., 2000; Umbricht & Kane, 1996). In addition, ap-
proximately 75% of persons with schizophrenia smoke more than two
packs of cigarettes per day (Casey, 2001), which compounds the risks
associated with obesity. Persons with schizophrenia also score less than
persons with no mental illness and persons with other mental illnesses
on physical activity and fitness measures (Chamove, 1986); physical
inactivity is one of the most prevalent risk factors for the development
of obesity and cardiovascular disease (U.S. Dept of Health and Human
Services, 1996).
Recent literature highlighting the obesity risks associated with atyp-
ical medications as well as the increasing media attention to obesity in
the United States have led mental health clinicians to a greater awareness
of the importance of assessing and facilitating the modification of risk
factors, such as through physical activity, in this at-risk population. In
the study described below, we compared the physical and mental health
parameters of an experimental group of randomly assigned outpatients
with schizophrenia participating in a structured 16-week treadmill walk-
ing program with those of a control group from the same population not
participating in the exercise program during the same time period. We
hypothesized that, at the conclusion of the exercise program, experimen-
tal participants would experience greater increases in 6-minute walking
distance (6MWD) and greater reductions in body mass index (BMI),
body fat, and psychiatric symptoms than controls.
BACKGROUND
Published reports on the effects of physical activity in persons with

schizophrenia are few in number and small in scope. Outpatient case
studies describing persons with schizophrenia have reported that exer-
cise was associated with improvements in social interest and reductions
in anxiety (Adams, 1995) as well as reductions in depression as mea-
sured by the Beck Depression Inventory (BDI; Beck & Steer, 1993;
Pelham, Campagna, Ritvo, & Birnie, 1993).
Gimino and Levin (1984) compared the Profile of Mood States
(POMS; McNair, Kerr, & Droppleman, 1971) scores of a group (n = 40)
of long-term hospitalized persons with schizophrenia undergoing a ten-
week aerobic exercise program with those of a control group (n = 40)
who were not entered in the exercise program. The experimental subjects
had significant reductions in depression and anxiety scores as measured
Effects of Exercise on Schizophrenia 663
by the POMS, however no significant differences were observed in self-

image. In contrast, Rosenthal and Beutell (1981) reported significant
improvement in body image scores as measured by human figure draw-
ings before and after a ten-week exercise program in a prettest-posttest
of a single group of persons with schizophrenia attending a day program
(N = 9).
Chamove (1986) examined short-term changes in the Nurses’ Ob-
servation Scale for Inpatient Evaluation (NOSIE; Honigfeld & Klett,
1965) scores in a single group of 40 long-term hospitalized persons with

schizophrenia after varying amounts and types of physical activity. All
subjects were rated better on all measures on active days than they were
on nonactive days. On active days, patients showed significant reduc-
tions in depression, tension, and psychotic features as measured by the
NOSIE and rated themselves as having improved social interaction.
Pelham and colleagues (1993) reported a series of three studies ex-
amining the effects of exercise on clients in a psychiatric rehabilitation
program. Of the 36 participants, 29 were persons with schizophrenia.
The first study (N = 11) involved eight weeks of aerobic (n = 5) or
nonaerobic (n = 6) exercise followed by a semi-structured interview.
Eighty-two percent of the participants associated exercise with reduc-

tions in depression and anxiety during semi-structured interviews. Par-
ticipants also reported increased energy levels and greater participation
in other aspects of the rehabilitation program. The authors did not dis-
cuss the differential response to aerobic versus nonaerobic exercise. In
the second study, randomly assigned aerobic exercisers (n = 5) had sig-
nificant reductions in depression, as measured by the BDI (Beck & Steer,
1993), along with increases in aerobic fitness (measured by submaximal
predicted oxygen consumption), as compared with five nonaerobic ex-
ercisers over a 12-week time period. The third study examined a single
group of 15 subjects who were not involved in a formal program but had
exercised regularly for at least 12 months. These subjects were given
a submaximal predicted oxygen consumption test along with the BDI.
A significant negative correlation was observed between aerobic fitness
and level of depression.
Vreeland and colleagues (2003) examined the effect of a 12-week
weight control program in a sample of 31 patients with schizophrenia or
schizoaffective disorder. Participants in the intervention group (n = 16)
received nutritional counseling and exercise teaching. BMIs of these
participants were compared with those of the control group (n = 16)
at the conclusion of the program. The intervention group had a statisti-
cally significant mean weight loss of 2.7 kg, as compared with a mean
weight gain of 2.9 kg for controls. In addition, the intervention group
experienced a statistically significant mean reduction in BMI of 0.98

points, as compared to a mean gain of 1.2 BMI points for controls. The
lack of randomization in this study may have biased these results toward
participants who were already motivated to lose weight at the outset of
the study.
Fogarty (2005) explored the benefits of a three-month exercise pro-
gram (unspecified) in a qualitative study of six residents of a Community
Care Unit in Australia. The subjects ranged in age from 20–42 years.
Exercise programs were individualized based upon fitness level. Fol-

lowing the exercise program, exercise staff conducted a focus group,
which elicited the following themes: the individual nature of the pro-
gram, physical improvements, positive group dynamics, and future plans
to continue exercising. Subjects described their ability to walk for longer
periods than was possible before the program, and reported weight loss
of varying amounts. Positive group dynamics identified by participants
included support and increased opportunities for socialization. The in-
dividualized nature of the program was important in that participants
increased their exercise gradually over time. This study supports the
findings of Chamove (1986) and Adams (1995), who also found exercise
to be associated with improvements in social functioning in inpatients

and outpatients with schizophrenia.
Most of the studies in this small body of literature use one-group
prettest-posttest designs or have other methodological limitations (no-
tably small sample sizes and lack of randomization). Nevertheless, these
studies consistently found physical exercise to be associated with reduc-
tions in depression and anxiety, and increased social interaction in per-
sons with schizophrenia in both inpatient and outpatient settings. Both
of the studies examining physical health parameters reported weight and
BMI reductions as well as increases in aerobic fitness in persons with
schizophrenia in response to exercise. The researchers also reported
increased socialization, reduced psychosis, and increased energy lev-
els, although these findings were not consistent across studies. The pilot
study described here will add to this literature by examining measures of
both physical and mental health as well as by using random assignment
to group.
METHOD
Sample and Setting
Participants were recruited from a population of persons with

schizophrenia receiving care at an outpatient clinic in a VA hospital
located in the Southeast. The center offers the full range of mental
health services, including educational programs, case management, out-
patient counseling, medication management, emergency screening and
crisis stabilization, as well as a 24-hour assessment and referral service.
Programs targeted specifically for persons with schizophrenia include
crisis stabilization, outpatient programs, and individual, group, and fam-
ily therapy. Trained professionals including psychiatrists, psychologists,
registered nurses, and social workers provide the services.
The sample was selected from clients meeting the following inclusion
criteria:
(a) A diagnosis of schizophrenia, any subtype, according to the criteria
described in the Diagnostic and Statistical Manual for Mental Dis-
orders (DSM-IV; American Psychiatric Association [APA], 2000a),
(b) Participation in the outpatient program, and
(c) Medical clearance for moderate exercise in writing from primary
care provider.
Exclusion criteria included evidence of significant cardiovascular, neu-
romuscular, endocrine, or other disorders that might prevent safe partic-
ipation in the study.

Prior to the study, both the University Institutional Review Board and
the recruitment facility research committee approved all procedures. All
eligible persons in the clinic were approached regarding study participa-
tion. Initially, study personnel presented a description of the study pro-
cedures and of the 16-week treadmill-walking program to small groups
of potential participants. Individual meetings with these individuals fol-
lowed in which study personnel reviewed records to ensure that diagnos-
tic criteria were met, explained the study in detail, answered questions,
and obtained written informed consent.
During the recruitment phase, 36 potential participants were identi-
fied from enrollees in the outpatient program. Of that number, 26 met
inclusion criteria, 12 agreed to participate, and 14 declined. The most
common reasons given for declining to participate were physical prob-
lems perceived by the individuals as limiting their participation, such as
back pain, or unwillingness to make a 16-week time commitment. The
12 persons agreeing to participate were randomly assigned to experi-
mental (n = 6) or control groups (n = 6) using a randomization schedule
designed by the statistician. Two persons who agreed to participate and
were assigned to the experimental group did not attend any scheduled
exercise sessions and were dropped, leaving ten participants who com-
pleted the study (four experimental and six control participants). The six
controls were offered the identical exercise program at the conclusion of
TABLE 1. Characteristics of Outpatients with

Schizophrenia (N = 10)
Characteristic n(%)
Sex
Male 8 (80)
Female 2 (20)
Race
Caucasian 8 (80)
African American 2 (20)
Marital Status
Single 7 (70)
Married 3 (30)
Living Arrangement
With family or roommate 7 (70)
With paid caregiver 1 (10)
Alone 2 (20)
Education
Less than high school 2 (20)
High school graduate 7 (70)
More than high school 1 (10)

Medications
Atypicals 9 (90)
Typicals 2 (20)
Antidepressants 2 (20)
Antianxiety 1 (10)
Antiparkinsonian 2 (20)
the study. The ten participants ranged in age from 40 to 63 with a mean
of 52 years. Most of the participants were high school graduates. The
majority of participants were male (n = 8) and Caucasian (n = 8). Most
of them were single (n = 7) and the majority lived with family or other
caregivers (n = 7). The most commonly prescribed medications were
atypical antipsychotics (90%). See Table 1 for a summary of participant
characteristics.
Data Collection
Data collection occurred over an approximately 13-month period.

All participants received letters of medical clearance from their primary
care provider prior to the initial collection of study measures. Following
the granting of medical clearance, data regarding sociodemographics
and prescribed medications were collected for all participants via record
review. Physical health parameters included 6-minute walking distance

(6MWD), body mass index (BMI), and percent body fat. Psychiatric
symptoms were measured using the Positive and Negative Syndrome
Scale (PANSS; Kay, Fiszbein, & Opler, 1987). A trained RA blinded to
treatment group performed all measures in private offices at the study
site. Measures were obtained at the outset and conclusion of the exercise
program on all participants and were assessed at the same time of day in
order to control for possible circadian variability and medication effects.
Participants were compensated for the time involved with grocery store
gift certificates.
6-Minute Walking Distance (6MWD)
6MWD was used to measure level of aerobic fitness. Participants
were instructed to wear walking shoes and loose clothing. A 200-foot-
long oval path was delineated, and participants were instructed to walk
around the path. Walks were timed with a stopwatch for six minutes
and measured to the nearest foot. Enright and Sherrill (1998) published
equations to estimate six-minute walking distance in healthy adults aged
40–80 as follows:
Male 6MWD = 7.57 × (ht in cm) − (5.02 × age) − 1.76 × (wt in kg)
− 309 meters
Female 6MWD = 2.11 × (ht in cm) − (2.29 × wt in kg) − (5.78 × age)
+ 667 meters
Body Mass Index (BMI)
Height in meters was measured using a wall stadiometer. Weight in
kilograms was measured using a balance-beam scale (Health-o-meter
model # 389532). Height and weight were used to calculate each partic-
ipant’s BMI (BMI = weight in kg/height in meters squared).
Percent Body Fat
Percent body fat was measured via sum of three skinfolds. Skinfolds
were measured to the nearest mm using a Lange skin caliper. The three-
site method measures the triceps, abdominal, and suprailiac skinfolds
(American College of Sports Medicine [ACSM], 1995). The triceps
skinfold measure was performed on a vertical fold on the posterior mid-
line of the upper right arm, with the arm held freely at the participant’s
side. The abdominal skinfold measure was performed on a vertical fold
2 cm to the right of the umbilicus. The suprailiac skinfold measure was
performed on a diagonal fold in the anterior axillary line immediately
superior to the iliac crest on the participant’s right side (ACSM, 1995).
Percent body fat was computed using the following equations (Jackson
& Pollock, 1985):
Males: Percent body fat = 0.39287 (sum of skinfolds) − 0.00105 (sum
of skinfolds squared) + 0.15772 (age) − 5.18845.
Females: Percent body fat = 0.41563 (sum of skinfolds) − 0.001122
(sum of skinfolds squared) + 0.03661 (age) + 4.03653.
Positive and Negative Syndrome Scale (PANSS) Scores

The PANSS (Kay, Fiszbein, & Opler, 1987) was designed to mea-
sure severity of psychopathology in adults with schizophrenia along
positive, negative, and general dimensions. Positive dimensions include
symptoms such as delusions, hallucinations, and bizarre behavior, while
negative dimensions include symptoms such as autistic thinking, with-
drawal, passivity, and isolation. The general dimension measures such
symptoms as anxiety, guilt, motor retardation and preoccupation (APA,
2000b). The PANSS includes 30 items scored on a Likert scale from 1
to 7; items are summed to determine the subscale and total scores, with
higher scores indicating greater severity of symptoms. Scores on the
positive and negative subscales range from 7 to 49; scores on the gen-
eral subscale range from 16 to 112. The measure is completed during
a structured interview and takes approximately 30 minutes to adminis-
ter and score. The PANSS has established good to excellent reliability
(Kay, 1990), internal consistency (Kay, Opler, & Lindenmayer, 1987),
and concurrent and predictive validity (Bell, Milstein, Beam-Goulet,
Lysaker, & Cicchetti, 1992). Cronbach’s alpha for this sample was 0.80.
Exercise Intervention
The treadmill exercise program met three times a week for 16 weeks
in a large room adjacent to the outpatient group room. Study person-
nel obtained treadmills and conducted exercise sessions. The program
consisted of ten minutes of warm-up stretches followed by treadmill
walking at target heart rate and ten minutes of cool-down stretches. Af-
ter being oriented to the equipment, experimental participants began
by walking for five minutes on the first day and gradually increased to
30 minutes over the first three weeks; they then walked for 30 minutes
each time they exercised for the remainder of the study. Control par-
ticipants did not participate in any exercises during this time period,
but were offered the identical exercise program at the conclusion of the
study. At the conclusion of the exercise program, physical and psycho-
logical measures were repeated on all participants. Table 2 contains the
TABLE 2. Written Information for Exercise Participants
After all the physical and mental health checks are done, you will begin the exercise group. The group meets for one hour 3 times a week for 4 months. You
should wear comfortable clothes and tennis shoes. The area below shows what will be done during each exercise group.
Week 1, Session 1 Week 1, Session 2 Week 1, Session 3
You will learn: You will practice taking the pulse in your neck. You will practice taking the pulse in your neck.
• about the target heart rate for your age You will do warm-up exercises. You will walk You will do warm-up exercises. You will walk
• how to take the pulse in your neck slowly on the treadmill for 10 minutes. You will slowly on the treadmill for 15 minutes. You will
• muscle-stretching warm-up exercises do cool-down exercises. do cool-down exercises.
• how to walk on the treadmill
• muscle-stretching cool–down exercises
You will walk slowly on the treadmill for
5 minutes.
Nurse will check how you are doing taking your You will do warm-up exercises. You will walk on You will do warm-up exercises. You will walk on
pulse; If you need help the nurse will help you. the treadmill for 10 minutes at your target heart the treadmill for 15 minutes at your target heart
You will do warm-up exercises. You will walk rate. You will do cool-down exercises. rate. You will do cool-down exercises.
on the treadmill for 5 minutes at your target
heart rate. You will do cool-down exercises.
You will do warm-up exercises. You will walk on You will do warm-up exercises. You will walk on You will do warm-up exercises. You will walk on
the treadmill for 15 minutes at your target heart the treadmill for 18 minutes at your target heart the treadmill for 21 minutes at your target heart
rate. You will do cool-down exercises. rate. You will do cool-down exercises. rate. You will do cool-down exercises.
You will do warm-up exercises. You will walk on You will do warm-up exercises. You will walk on You will do warm-up exercises. You will walk on
the treadmill for 24 minutes at your target heart the treadmill for 27 minutes at your target heart the treadmill for 30 minutes at your target heart
rate. You will do cool-down exercises. rate. You will do cool-down exercises. rate. You will do cool-down exercises.
During weeks 5–16, the exercise group will continue to meet three times a week. You will do warm-up exercises first each time. You will walk on the
treadmill for 30 minutes at your target heart rate. After your walk, you will do cool-down exercises.
669
written information that was provided to exercise participants to orient

them to the program. Attendance ranged from 43% to 91% of sessions
attended out of total sessions offered; 75% of participants attended more
than half of the sessions, and 50% attended over 2/3. The most common
reason reported for a missed exercise session was conflict with another
appointment.
RESULTS
No significant pre-exercise differences between the two groups were

found for any sociodemographic or illness variables. Table 3 presents the
baseline and final measures for the two groups. Due to the small sample
sizes and violation of the normality assumption for some variables, non-
parametric analysis was performed. All hypotheses were tested using
the one-sided Wilcoxon rank sum test. The results for all hypotheses
were in the predicted direction. Table 4 presents the differences in group
means for the variables measured.
Hypothesis 1 was that experimental participants would have greater
gains in 6MWD than controls (indicating better aerobic fitness). Exper-
imental participants increased their 6MWD by an average of 152 feet

from baseline to end of the study, as compared to controls who increased
their 6MWD by 56 feet (see Table 4). Although this represents an approx-
imately 10% increase in distance walked for experimental participants
and a 3-fold improvement over controls, the difference between groups
was not statistically significant.
Hypothesis 2 stated that experimental participants would have greater
reductions in BMI as compared to controls. Experimental participants
TABLE 3. Baseline and Final Measures of Persons with Schizophrenia

(N = 10)
Mean difference
from baseline
Group Measure Baseline mean Final mean to endpoint
Experimental 6MWD 1412.25 1564.75 +152.5
(n = 4) BMI 32.51 31.27 −1.27
Percent fat 25.65 21.96 −3.69
PANSS total 69.25 61 −8.25
Control 6MWD 1381.33 1438 56.66
(n = 6) BMI 30.07 29.93 −0.14
Percent fat 25.13 25.11 −0.02
PANSS total 67.17 71.83 +4.66
TABLE 4. Experimental Group Minus Control

Group Means (N = 10)
Baseline
difference in Final difference
Measure group means in group means
6MWD 30.92 126.75
BMI 2.44 1.34
Percent fat 0.52 3.15∗

PANSS total 2.08 10.83
Note: Baseline = Difference in group means at baseline;
Final = Difference in group means at post-test.
∗ p < 0.05.
reduced their BMIs by an average of 1.3% in contrast to a reduction of

0.14% in control participants. This difference also was not statistically
significant (see Table 4).
Hypothesis 3 was that experimental participants would experience
greater reductions in body fat than those in the control group. Experi-
mental participants reduced their body fat by an average of 3.7%, which

was significantly greater than the average 0.02% reduction achieved by
the control group ( p = 0.03) (see Table 4).
Hypothesis 4 stated that experimental participants would experience
greater reductions on PANSS scores than controls. Experimental par-
ticipants experienced an eight-point drop in their average total PANSS
scores, as compared to an average increase of four points for controls.
In addition, experimental participants experienced a 2.75-point drop
in positive symptoms, a 1.75-point drop in negative symptoms and a
3-point drop in general symptoms on average. On the other hand, the
control group experienced a 0.66-point increase in positive symptoms,
a 1.5-point increase in negative symptoms and a 2.3-point increase in
general symptoms on average at the conclusion of the study. While these
differences did not approach statistical significance, they represent clin-
ically meaningful changes in symptom level for the exercise group. In
particular the PANSS total score reflects a 12-point difference between
the average scores of the two groups at the conclusion of the exercise
program (see Table 4).
DISCUSSION
It appears that a short-term treadmill-walking program offers

both statistically and clinically significant benefits to veterans with
schizophrenia. Participants attending the walking group experienced

significant reductions in their percentages of body fat as compared to
controls. In addition, participants in the experimental group increased
their aerobic fitness as measured by the 6MWD, reduced their BMIs,
and had fewer psychiatric symptoms at the conclusion of the exercise
program.
Of interest is our finding of slightly improved measures on physical
health parameters in control subjects not participating in the exercise
program. Participants in the control group increased their mean 6MWD

by 56 feet, an approximate 5% increase over their baseline mean. It is
likely that some practice effect may have been involved that allowed all
participants to walk slightly more rapidly the second time the measure
was done. In addition, control participants reduced their average BMIs
by 0.14% and reduced their average body fat by 0.02% during the study.
While these reductions are very small, a possible explanation that should
be considered is greater participation in exercise opportunities outside
the study by control participants. Since all participants were aware of the
exercise component when they agreed to participate, it seems reason-
able to conclude that even those persons who were randomly assigned to
the control group initially gave consent because of their interest in and
willingness to exercise. Hearing others discussing the treadmill program
and observing their progress may have prompted them to increase their
activity level on their own. It is important to note that the magnitude
of these pre- and posttest differences is small as compared to those for
experimental participants. For instance, controls improved their 6MWD
approximately 1/3 as much as experimental participants, and reduced
their BMIs only 1/10 much as experimental participants. Body fat reduc-
tions in the control group were miniscule. Further, these improvements
were not reflected in our measures of psychiatric symptoms, rather con-
trol subjects’ scores actually increased on average during the course of
the study.
Our results of reductions in psychiatric symptoms as measured by the
PANSS are congruent with the findings of Gimino and Levin (1984) as
well as Pelham and colleagues (1993) that aerobic exercise significantly
reduced depression and anxiety in persons with schizophrenia. In addi-
tion, we report reductions in PANSS positive symptoms post-exercise,
in agreement with Chamove’s (1986) report of reduced psychotic symp-
toms in a hospitalized sample on days of increased physical activity.
Although participants in our study were older, as a group, than those
interviewed by Fogarty (2005), there are similarities in responses to
exercise in the two studies. Our walking program provided for grad-
ually increasing length of exercise, which was cited as important by
Fogarty’s participants. Likewise, our finding of increased 6MWD in ex-

ercisers agrees with the self-reported improvements in fitness in their
sample.
To our knowledge this is the first study to examine the outcome of
6MWD for persons with schizophrenia in response to exercise. The
6MWD is a quick, easy, inexpensive and noninvasive way to measure
fitness and exercise capacity that can be easily adopted in a variety
of inpatient and outpatient psychiatric settings. Researchers conduct-
ing follow-up studies should consider this measure in the interest of

enhancing comparability across studies.
LIMITATIONS
The difficulties of conducting methodologically superior studies of

exercise as an adjunct for schizophrenia are many. Responses to exercise
and preferred modalities are highly individualized, making it difficult to
design programs for maximum appeal to the majority of persons. The dis-
ease of schizophrenia includes wide variability in baseline functioning,
motivation, pharmacologic treatments and the like, which makes draw-

ing comparisons across populations problematic. Clinical studies are
further hampered by concerns over adequate diagnosis of schizophrenia
and comorbid conditions that could affect exercise response. And fi-
nally, differences across inpatient, outpatient, Veterans Administration,
and community settings hamper generalizability (Faulkner & Biddle,
1999).
In regard to our study specifically, selection bias may pose a threat to
internal validity. The recruitment of participants was problematic, with
over half of eligible persons declining to participate. One explanation for
this difficulty is the nature of symptoms of schizophrenia, which often
include paranoia and lack of emotional involvement with others. Thus,
those with the greatest severity of illness may have refused, leaving
those with fewer psychiatric symptoms to participate in the study. Al-
ternatively, those who were more interested in fitness and exercise may
have elected to participate at higher rates than others. This may be a par-
tial explanation for the small improvements in the physical parameters
of control participants.
The large proportion of males in Veterans’ settings along with the
small sample size and the nature of pilot data limit the generalizabil-
ity of this study. Further, the diagnosis of schizophrenia in veterans
is associated with federal disability designation that generates income
and leads to other veterans’ benefits, including medical and psychiatric
care, case management, and housing support, that are not as readily
available to nonveterans with this disease. Thus, disabled veterans with
schizophrenia have higher socioeconomic status, as well as access to
care and support at much higher levels, than nonveterans. These factors
may contribute to differing responses to exercise interventions and ad-
herence rates among populations. Nevertheless, these pilot data seem to
suggest that these advantages have not translated into overall improve-
ments in physical health parameters in our sample and that veterans
with schizophrenia could benefit from increased attention to their phys-

ical health parameters and activity levels generally.
IMPLICATIONS FOR FURTHER STUDY
Future studies should increase sample size and length of exercise

program to the extent possible within time and resource constraints.
Investigators need to explore creative ways to enhance recruitment and
retention. Research personnel noted that joint and muscle flexibility
of exercise participants was dramatically increased as the treadmill-
walking program progressed. Measures of flexibility could be added
to future investigations to explore this anecdotal finding. Additional

studies also are needed to systematically examine the interactions of
medications with the effects of exercise, as well as any differences in
outcomes based on type, frequency, and duration of exercise sessions to
examine responses to different exercise “dosages.”
Lastly, research is needed to identify the most effective exercise in-
terventions and the most feasible delivery modalities for persons with
schizophrenia in community settings (Robbins et al., 2001). A future
inquiry could offer additional exercise options other than treadmills,
perhaps stair-steppers or rowing machines, and monitor participant re-
sponses and compliance. Practitioners need to be consistent and per-
sistent in encouraging patients to be physically active in a variety of
settings, provide positive reinforcement for activities in which clients
are willing to engage, and continue to highlight the benefits to physical
as well as mental health.
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Issues in Mental Health Nursing, 26:661–676, 2005

Copyright c Taylor & Francis Inc.

EFFECTS OF EXERCISE ON MENTAL

Lora Humphrey Beebe, PhD, RN

Although the benefits of exercise are well documented, few

published research studies have examined exercise in

Persons with schizophrenia face many challenges in maintaining their

Address correspondence to Lora Humphrey Beebe, University of Florida, College of Nursing,

Published reports on the effects of physical activity in persons with

by the POMS, however no significant differences were observed in self-

1965) scores in a single group of 40 long-term hospitalized persons with

Eighty-two percent of the participants associated exercise with reduc-

experienced a statistically significant mean reduction in BMI of 0.98

Exercise programs were individualized based upon fitness level. Fol-

to be associated with improvements in social functioning in inpatients

Sample and Setting

Participants were recruited from a population of persons with

ipation in the study.

TABLE 1. Characteristics of Outpatients with

More than high school 1 (10)

Data collection occurred over an approximately 13-month period.

review. Physical health parameters included 6-minute walking distance

Positive and Negative Syndrome Scale (PANSS) Scores

TABLE 2. Written Information for Exercise Participants

written information that was provided to exercise participants to orient

No significant pre-exercise differences between the two groups were

imental participants increased their 6MWD by an average of 152 feet

TABLE 3. Baseline and Final Measures of Persons with Schizophrenia

TABLE 4. Experimental Group Minus Control

Percent fat 0.52 3.15∗

reduced their BMIs by an average of 1.3% in contrast to a reduction of

mental participants reduced their body fat by an average of 3.7%, which

It appears that a short-term treadmill-walking program offers

schizophrenia. Participants attending the walking group experienced

program. Participants in the control group increased their mean 6MWD

Fogarty’s participants. Likewise, our finding of increased 6MWD in ex-

ing follow-up studies should consider this measure in the interest of

The difficulties of conducting methodologically superior studies of

motivation, pharmacologic treatments and the like, which makes draw-

with schizophrenia could benefit from increased attention to their phys-

IMPLICATIONS FOR FURTHER STUDY

Future studies should increase sample size and length of exercise

to future investigations to explore this anecdotal finding. Additional

study. Perceptual and Motor Skills, 53(3), 758.

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