Hostname: page-component-5cf477f64f-tgq86 Total loading time: 0 Render date: 2025-03-30T08:34:17.944Z Has data issue: false hasContentIssue false
  • English
  • Français

A systematic review and meta-analysis of exercise interventions in schizophrenia patients

Published online by Cambridge University Press:  04 February 2015

J. Firth ,
J. Cotter ,
R. Elliott ,
P. French  and
A. R. Yung
J. Firth*
Affiliation:
Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
J. Cotter
Affiliation:
Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
R. Elliott
Affiliation:
Institute of Brain, Behaviour and Mental Health, University of Manchester, UK Manchester Academic Health Sciences Centre, University of Manchester, UK
P. French
Affiliation:
Psychosis Research Unit, Greater Manchester West NHS Mental Health Trust, UK Institute of Psychology, Health and Society, The University of Liverpool, UK
A. R. Yung
Affiliation:
Institute of Brain, Behaviour and Mental Health, University of Manchester, UK Orygen Youth Health Research Centre, University of Melbourne, Australia
*
* Address for correspondence: J. Firth, University of Manchester, Room 3.306, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

The typically poor outcomes of schizophrenia could be improved through interventions that reduce cardiometabolic risk, negative symptoms and cognitive deficits; aspects of the illness which often go untreated. The present review and meta-analysis aimed to establish the effectiveness of exercise for improving both physical and mental health outcomes in schizophrenia patients.

Method

We conducted a systematic literature search to identify all studies that examined the physical or mental effects of exercise interventions in non-affective psychotic disorders. Of 1581 references, 20 eligible studies were identified. Data on study design, sample characteristics, outcomes and feasibility were extracted from all studies and systematically reviewed. Meta-analyses were also conducted on the physical and mental health outcomes of randomized controlled trials.

Results

Exercise interventions had no significant effect on body mass index, but can improve physical fitness and other cardiometabolic risk factors. Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week (standardized mean difference: 0.72, 95% confidence interval −1.14 to −0.29). This amount of exercise was also reported to significantly improve functioning, co-morbid disorders and neurocognition.

Conclusions

Interventions that implement a sufficient dose of exercise, in supervised or group settings, can be feasible and effective interventions for schizophrenia.

Keywords

Exercisefunctional recoveryphysical activitypsychotic disordersschizophrenia
Type
Review Article
Information
Psychological Medicine , Volume 45 , Issue 7 , May 2015 , pp. 1343 - 1361
Copyright
Copyright © Cambridge University Press 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Abdel-Baki, A, Brazzini-Poisson, V, Marois, F, Letendre, T, Karelis, AD (2013). Effects of aerobic interval training on metabolic complications and cardiorespiratory fitness in young adults with psychotic disorders: a pilot study. Schizophrenia Research 149, 112–115.CrossRefGoogle ScholarPubMed
Acil, AA, Dogan, S, Dogan, O (2008). The effects of physical exercises to mental state and quality of life in patients with schizophrenia. Journal of Psychiatric and Mental Health Nursing 15, 808–815.CrossRefGoogle ScholarPubMed
Albert, N, Bertelsen, M, Thorup, A, Petersen, L, Jeppesen, P, Le Quack, P, Krarup, G, Jørgensen, P, Nordentoft, M (2011). Predictors of recovery from psychosis: analyses of clinical and social factors associated with recovery among patients with first-episode psychosis after 5 years. Schizophrenia Research 125, 257–266.CrossRefGoogle ScholarPubMed
Alberti, KGM, Zimmet, P, Shaw, J (2005). The metabolic syndrome – a new worldwide definition. Lancet 366, 1059–1062.CrossRefGoogle ScholarPubMed
Alvarez-Jiménez, M, Gleeson, J, Henry, L, Harrigan, S, Harris, M, Killackey, E, Bendall, S, Amminger, G, Yung, A, Herrman, H (2012). Road to full recovery: longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years. Psychological Medicine 42, 595.CrossRefGoogle ScholarPubMed
Alvarez-Jiménez, M, Gonzalez-Blanch, C, Crespo-Facorro, B, Hetrick, S, Rodriguez-Sanchez, JM, Perez-Iglesias, R, Luis, J (2008 a). Antipsychotic-induced weight gain in chronic and first-episode psychotic disorders. CNS Drugs 22, 547–562.CrossRefGoogle ScholarPubMed
Alvarez-Jiménez, M, Hetrick, SE, González-Blanch, C, Gleeson, JF, Mcgorry, PD (2008 b). Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials. British Journal of Psychiatry 193, 101–107.CrossRefGoogle ScholarPubMed
Andreasen, NC, Nopoulos, P, Magnotta, V, Pierson, R, Ziebell, S, Ho, B-C (2011). Progressive brain change in schizophrenia: a prospective longitudinal study of first-episode schizophrenia. Biological Psychiatry 70, 672–679.CrossRefGoogle ScholarPubMed
Angevaren, M, Aufdemkampe, G, Verhaar, H, Aleman, A, Vanhees, L (2008). Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005381. doi:10.1002/14651858.CD005381.pub2.CrossRefGoogle ScholarPubMed
Archie, S, Wilson, JH, Osborne, S, Hobbs, H, Mcniven, J (2003). Pilot study: access to fitness facility and exercise levels in olanzapine-treated patients. Canadian Journal of Psychiatry 48, 628–632.CrossRefGoogle ScholarPubMed
Battaglia, G, Alesi, M, Inguglia, M, Roccella, M, Caramazza, G, Bellafiore, M, Palma, A (2013). Soccer practice as an add-on treatment in the management of individuals with a diagnosis of schizophrenia. Neuropsychiatric Disease and Treatment 9, 595–603.Google Scholar
Beebe, LH, Tian, L, Morris, N, Goodwin, A, Allen, SS, Kuldau, J (2005). Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues in Mental Health Nursing 26, 661–676.Google Scholar
Behere, RV, Arasappa, R, Jagannathan, A, Varambally, S, Venkatasubramanian, G, Thirthalli, J, Subbakrishna, DK, Nagendra, HR, Gangadhar, BN (2011). Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatrica Scandinavica 123, 147–153.CrossRefGoogle ScholarPubMed
Bonfioli, E, Berti, L, Goss, C, Muraro, F, Burti, L (2012). Health promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trials. BMC Psychiatry 12, 78.CrossRefGoogle ScholarPubMed
Bredin, SSD, Warburton, DER, Lang, DJ (2013). The health benefits and challenges of exercise training in persons living with schizophrenia: a pilot study. Brain Sciences 3, 821–848.Google Scholar
Bustillo, JR, Lauriello, J, Horan, WP, Keith, SJ (2001). The psychosocial treatment of schizophrenia: an update. American Journal of Psychiatry 158, 163–175.CrossRefGoogle ScholarPubMed
Caspersen, CJ, Powell, KE, Christenson, GM (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports 100, 126.Google ScholarPubMed
Cooney, GM, Dwan, K, Greig, CA, Lawlor, DA, Rimer, J, Waugh, FR, Mcmurdo, M, Mead, GE (2013). Exercise for depression. Cochrane Database of Systematic Reviews Issue 9. Art. No.: CD004366. doi:10.1002/14651858.CD004366.pub6.CrossRefGoogle ScholarPubMed
Crespo-Facorro, B, Perez-Iglesias, R, Ramirez-Bonilla, M, Martínez-García, O, Llorca, J, Luis, V-BJ (2006). A practical clinical trial comparing haloperidol, risperidone, and olanzapine for the acute treatment of first-episode nonaffective psychosis. Journal of Clinical Psychiatry 67, 1511–1521.CrossRefGoogle ScholarPubMed
De Haan, L, Linszen, DH, Lenior, ME, De Win, ED, Gorsira, R (2003). Duration of untreated psychosis and outcome of schizophrenia: delay in intensive psychosocial treatment versus delay in treatment with antipsychotic medication. Schizophrenia Bulletin 29, 341–348.Google Scholar
De Hert, M, Schreurs, V, Sweers, K, Van Eyck, D, Hanssens, L, Šinko, S, Wampers, M, Scheen, A, Peuskens, J, Van Winkel, R (2008). Typical and atypical antipsychotics differentially affect long-term incidence rates of the metabolic syndrome in first-episode patients with schizophrenia: a retrospective chart review. Schizophrenia Research 101, 295–303.CrossRefGoogle ScholarPubMed
Dersimonian, R, Laird, N (1986). Meta-analysis in clinical trials. Controlled Clinical Trials 7, 177–188.CrossRefGoogle ScholarPubMed
Dishman, RK (1991). Increasing and maintaining exercise and physical activity. Behavior Therapy 22, 345–378.CrossRefGoogle Scholar
Dodd, KJ, Duffy, S, Stewart, JA, Impey, J, Taylor, N (2011). A small group aerobic exercise programme that reduces body weight is feasible in adults with severe chronic schizophrenia: a pilot study. Disability and Rehabilitation 33, 1222–1229.Google Scholar
Duraiswamy, G, Thirthalli, J, Nagendra, HR, Gangadhar, BN (2007). Yoga therapy as an add-on treatment in the management of patients with schizophrenia – a randomized controlled trial. Acta Psychiatrica Scandinavica 116, 226–232.CrossRefGoogle ScholarPubMed
Erhart, SM, Marder, SR, Carpenter, WT (2006). Treatment of schizophrenia negative symptoms: future prospects. Schizophrenia Bulletin 32, 234–237.CrossRefGoogle ScholarPubMed
Falkai, P, Malchow, B, Wobrock, T, Gruber, O, Schmitt, A, Honer, WG, Pajonk, FG, Sun, F, Cannon, TD (2013). The effect of aerobic exercise on cortical architecture in patients with chronic schizophrenia: a randomized controlled MRI study. European Archives of Psychiatry and Clinical Neuroscience 263, 469–473.Google Scholar
Fernández-San-Martín, MI, Martín-López, LM, Masa-Font, R, Olona-Tabueña, N, Roman, Y, Martin-Royo, J, Oller-Canet, S, González-Tejón, S, San-Emeterio, L, Barroso-Garcia, A (2014). The effectiveness of lifestyle interventions to reduce cardiovascular risk in patients with severe mental disorders: meta-analysis of intervention studies. Community Mental Health Journal 50, 81–95.CrossRefGoogle ScholarPubMed
Fogelholm, M (2010). Physical activity, fitness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obesity Reviews 11, 202–221.Google Scholar
Foley, DL, Morley, KI (2011). Systematic review of early cardiometabolic outcomes of the first treated episode of psychosis. Archives of General Psychiatry 68, 609.Google Scholar
Galderisi, S, Mucci, A, Bitter, I, Libiger, J, Bucci, P, Wolfgang Fleischhacker, W, Kahn, RS (2013). Persistent negative symptoms in first episode patients with schizophrenia: results from the European First Episode Schizophrenia Trial. European Neuropsychopharmacology 23, 196–204.CrossRefGoogle ScholarPubMed
Garber, CE, Blissmer, B, Deschenes, MR, Franklin, BA, Lamonte, MJ, Lee, IM, Nieman, DC, Swain, DP; American College of Sports Medicine (2011). American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Medicine and Science in Sports and Exercise 43, 1334–1359.Google Scholar
Gholipour, A, Abolghasemi, SH, Gholinia, K, Taheri, S (2012). Token reinforcement therapeutic approach is more effective than exercise for controlling negative symptoms of schizophrenic patients: a randomized controlled trial. International Journal of Preventive Medicine 3, 466–470.Google Scholar
Goldberg, TE, Goldman, RS, Burdick, KE, Malhotra, AK, Lencz, T, Patel, RC, Woerner, MG, Schooler, NR, Kane, JM, Robinson, DG (2007). Cognitive improvement after treatment with second-generation antipsychotic medications in first-episode schizophrenia: is it a practice effect? Archives of General Psychiatry 64, 1115.CrossRefGoogle ScholarPubMed
Gorczynski, P, Faulkner, G (2010). Exercise therapy for schizophrenia. Cochrane Database of Systematic Reviews Issue 5. Art. No.: CD004412. doi:10.1002/14651858.CD004412.pub2.CrossRefGoogle ScholarPubMed
Green, MF (1996). What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry 153, 321–330.Google ScholarPubMed
Heggelund, J, Morken, G, Helgerud, J, Nilsberg, GE, Hoff, J (2012). Therapeutic effects of maximal strength training on walking efficiency in patients with schizophrenia – a pilot study. BMC Research Notes 5, 344.CrossRefGoogle ScholarPubMed
Heggelund, J, Nilsberg, GE, Hoff, J, Morken, G, Helgerud, J (2011). Effects of high aerobic intensity training in patients with schizophrenia – a controlled trial. Nordic Journal of Psychiatry 65, 269–275.CrossRefGoogle ScholarPubMed
Hennekens, CH, Hennekens, AR, Hollar, D, Casey, DE (2005). Schizophrenia and increased risks of cardiovascular disease. American Heart Journal 150, 1115–1121.Google Scholar
Hert, M, Schreurs, V, Vancampfort, D, Winkel, R (2009). Metabolic syndrome in people with schizophrenia: a review. World Psychiatry 8, 15–22.Google Scholar
Higgins, J, Altman, DG, Gøtzsche, PC, Jüni, P, Moher, D, Oxman, AD, Savović, J, Schulz, KF, Weeks, L, Sterne, JA (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ (Clinical Research Ed.) 343, d5928.Google Scholar
Higgins, JP, Green, S (2008). Cochrane Handbook for Systematic Reviews of Interventions. John Wiley & Sons Ltd: Chichester.CrossRefGoogle Scholar
Janssen, I, Katzmarzyk, PT, Ross, R (2004). Waist circumference and not body mass index explains obesity-related health risk. American Journal of Clinical Nutrition 79, 379–384.Google Scholar
Kern, RS, Glynn, SM, Horan, WP, Marder, SR (2009). Psychosocial treatments to promote functional recovery in schizophrenia. Schizophrenia Bulletin 35, 347–361.CrossRefGoogle ScholarPubMed
Kirkpatrick, B, Fenton, WS, Carpenter, WT, Marder, SR (2006). The NIMH-MATRICS consensus statement on negative symptoms. Schizophrenia Bulletin 32, 214–219.Google Scholar
Knapp, M, Mangalore, R, Simon, J (2004). The global costs of schizophrenia. Schizophrenia Bulletin 30, 279–293.Google Scholar
Kodama, S, Saito, K, Tanaka, S, Maki, M, Yachi, Y, Asumi, M, Sugawara, A, Totsuka, K, Shimano, H, Ohashi, Y (2009). Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women. JAMA: The Journal of the American Medical Association 301, 2024–2035.CrossRefGoogle ScholarPubMed
Laursen, TM (2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research 131, 101–104.CrossRefGoogle ScholarPubMed
Lee, EH, Hui, CL, Chang, W, Chan, SK, Li, Y, Lee, J, Lin, JJ, Chen, EY (2013). Impact of physical activity on functioning of patients with first-episode psychosis – a 6 months prospective longitudinal study. Schizophrenia Research 150, 538–541.CrossRefGoogle ScholarPubMed
Malla, A, Norman, R, Schmitz, N, Manchanda, R, Bechard-Evans, L, Takhar, J, Haricharan, R (2006). Predictors of rate and time to remission in first-episode psychosis: a two-year outcome study. Psychological Medicine 36, 649–658.CrossRefGoogle ScholarPubMed
Mangalore, R, Knapp, M (2007). Cost of schizophrenia in England. Journal of Mental Health Policy and Economics 10, 23.Google ScholarPubMed
Manjunath, RB, Varambally, S, Thirthalli, J, Basavaraddi, IV, Gangadhar, BN (2013). Efficacy of yoga as an add-on treatment for in-patients with functional psychotic disorder. Indian Journal of Psychiatry 55, S374–S378.Google ScholarPubMed
Martin, JLR, Pérez, V, Sacristán, M, Rodríguez-Artalejo, F, Martínez, C, Álvarez, E (2006). Meta-analysis of drop-out rates in randomised clinical trials, comparing typical and atypical antipsychotics in the treatment of schizophrenia. European Psychiatry 21, 11–20.CrossRefGoogle ScholarPubMed
Marzolini, S, Jensen, B, Melville, P (2009). Feasibility and effects of a group-based resistance and aerobic exercise program for individuals with severe schizophrenia: a multidisciplinary approach. Mental Health and Physical Activity 2, 29–36.CrossRefGoogle Scholar
McGowan, S, Iqbal, Z, Birchwood, M (2008). Early interventions in psychosis. In Mental Health: From Policy to Practice (ed. Brooker, C., Repper, J. and Brown, M.), pp. 137–150. Elsevier: Oxford.Google Scholar
McIntosh, AM, Owens, DC, Moorhead, WJ, Whalley, HC, Stanfield, AC, Hall, J, Johnstone, EC, Lawrie, SM (2011). Longitudinal volume reductions in people at high genetic risk of schizophrenia as they develop psychosis. Biological Psychiatry 69, 953–958.CrossRefGoogle ScholarPubMed
McNamee, L, Mead, G, MacGillivray, S, Lawrie, SM (2013). Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities. British Journal of Psychiatry 203, 239–241.Google Scholar
Morgan, AJ, Parker, AG, Alvarez-Jimenez, M, Jorm, AF (2013). Exercise and mental health: an Exercise and Sports Science Australia commissioned review. Journal of Exercise Physiology Online 16, 64–73.Google Scholar
Myers, J, Kaykha, A, George, S, Abella, J, Zaheer, N, Lear, S, Yamazaki, T, Froelicher, V (2004). Fitness versus physical activity patterns in predicting mortality in men. American Journal of Medicine 117, 912–918.Google Scholar
National Institute for Health and Care Excellence (2014). Psychosis and Schizophrenia in Adults: Treatment and Management (Clinical guideline 178). National Institute for Health and Care Excellence: London.Google Scholar
National Institute for Health and Clinical Excellence (2010). Schizophrenia: The NICE Guideline on Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Updated edition). The British Psychological Society and the Royal College of Psychiatrists: London.Google Scholar
Pajonk, FG, Wobrock, T, Gruber, O, Scherk, H, Berner, D, Kaizl, I, Kierer, A, Muller, S, Oest, M, Meyer, T, Backens, M, Schneider-Axmann, T, Thornton, AE, Honer, WG, Falkai, P (2010). Hippocampal plasticity in response to exercise in schizophrenia. Archives of General Psychiatry 67, 133–143.CrossRefGoogle ScholarPubMed
Perraton, LG, Kumar, S, Machotka, Z (2010). Exercise parameters in the treatment of clinical depression: a systematic review of randomized controlled trials. Journal of Evaluation in Clinical Practice 16, 597–604.CrossRefGoogle ScholarPubMed
Phutane, VH, Tek, C, Chwastiak, L, Ratliff, JC, Ozyuksel, B, Woods, SW, Srihari, VH (2011). Cardiovascular risk in a first-episode psychosis sample: a ‘critical period’ for prevention? Schizophrenia Research 127, 257–261.Google Scholar
Rabinowitz, J, Levine, SZ, Garibaldi, G, Bugarski-Kirola, D, Berardo, CG, Kapur, S (2012). Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophrenia Research 137, 147–150.Google Scholar
Robison, J, Rogers, MA (1994). Adherence to exercise programmes. Sports Medicine 17, 39–52.CrossRefGoogle ScholarPubMed
Scheewe, TW, Backx, FJG, Takken, T, Jorg, F, Van Strater, ACP, Kroes, AG, Kahn, RS, Cahn, W (2013 a). Exercise therapy improves mental and physical health in schizophrenia: a randomised controlled trial. Acta Psychiatrica Scandinavica 127, 464–473.Google Scholar
Scheewe, TW, Takken, T, Kahn, RS, Cahn, W, Backx, FJG (2012). Effects of exercise therapy on cardiorespiratory fitness in patients with schizophrenia. Medicine and Science in Sports and Exercise 44, 1834–1842.CrossRefGoogle ScholarPubMed
Scheewe, TW, Van Haren, NEM, Sarkisyan, G, Schnack, HG, Brouwer, RM, De Glint, M, Hulshoff Pol, HE, Backx, FJG, Kahn, RS, Cahn, W (2013 b). Exercise therapy, cardiorespiratory fitness and their effect on brain volumes: a randomised controlled trial in patients with schizophrenia and healthy controls. European Neuropsychopharmacology 23, 675–685.Google Scholar
Schizophrenia Commission (2012). The Abandoned Illness: A Report from the Schizophrenia Commission. Rethink Mental Illness: London.Google Scholar
Schwartz, JE, Fennig, S, Tanenberg-Karant, M, Carlson, G, Craig, T, Galambos, N, Lavelle, J, Bromet, EJ (2000). Congruence of diagnoses 2 years after a first-admission diagnosis of psychosis. Archives of General Psychiatry 57, 593–600.Google Scholar
Scott, CL (2003). Diagnosis, prevention, and intervention for the metabolic syndrome. American Journal of Cardiology 92, 35–42.CrossRefGoogle ScholarPubMed
Smith, PJ, Blumenthal, JA, Hoffman, BM, Cooper, H, Strauman, TA, Welsh-Bohmer, K, Browndyke, JN, Sherwood, A (2010). Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosomatic Medicine 72, 239–252.CrossRefGoogle ScholarPubMed
Vancampfort, D, Knapen, J, Probst, M, Scheewe, T, Remans, S, De Hert, M (2012 a). A systematic review of correlates of physical activity in patients with schizophrenia. Acta Psychiatrica Scandinavica 125, 352–362.Google Scholar
Vancampfort, D, Probst, M, Scheewe, T, Knapen, J, De Herdt, A, De Hert, M (2012 b). The functional exercise capacity is correlated with global functioning in patients with schizophrenia. Acta Psychiatrica Scandinavica 125, 382–387.Google Scholar
Vancampfort, D, Probst, M, Sweers, K, Maurissen, K, Knapen, J, Willems, J, Heip, T, De Hert, M (2012 c). Eurofit test battery in patients with schizophrenia or schizoaffective disorder: reliability and clinical correlates. European Psychiatry 27, 416–421.CrossRefGoogle ScholarPubMed
Vancampfort, D, Wampers, M, Mitchell, AJ, Correll, CU, Herdt, A, Probst, M, Hert, M (2013). A meta-analysis of cardio-metabolic abnormalities in drug naïve, first-episode and multi-episode patients with schizophrenia versus general population controls. World Psychiatry 12, 240–250.Google Scholar
Varambally, S, Gangadhar, BN, Thirthalli, J, Jagannathan, A, Kumar, S, Venkatasubramanian, G, Muralidhar, D, Subbakrishna, DK, Nagendra, HR (2012). Therapeutic efficacy of add-on yoga as an intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian Journal of Psychiatry 54, 227–232.Google Scholar
World Health Organization (2010). Global Recommendations on Physical Activity for Health, pp. 8–10. World Health Organization: Geneva.Google Scholar