Title: A cognitive intervention to increase physical activity in people with schizophrenia
Funder: Health Education England

Abstract: 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.

Lay abstract: 'I spent a great deal of time sitting on the couch watching TV. I was lethargic, and lame from inactivity.' A patient diagnosed with schizophrenia Aim The aim of the research is to help people who have a diagnosis of schizophrenia become more physically active. Background People diagnosed with schizophrenia die 15 years earlier than others and are three times more likely to have poor physical health. There are many causes of this poor physical health but one important cause is inactivity: 1) patients exercise less and 2) they spend more time sitting (sedentary behaviour). On average, patients with schizophrenia spend more than double the time sitting down than people without the diagnosis. Being physically inactive raises the risk of diseases of the heart and lungs. It can also contribute to making people depressed, sleep badly, and lose friendships. Physical activity is then even less likely. The project The importance of this topic has led to attempts to increase physical activity for this patient group but the outcomes to date have been disappointing. There are three main reasons for this: 1). interventions have not paid enough attention to psychological barriers to activity 2). interventions have not addressed sedentary behaviour and 3). interventions have not been designed alongside people diagnosed with schizophrenia. In this project we will design a new intervention, which will overcome these previous limitations. 1). Three important psychological barriers will be addressed: depression, fear, and low motivation. At a psychological (cognitive) level these barriers can be understood as patients not being physically active because of thinking certain thoughts (e.g. that they will not succeed, something bad may happen, and that there will be insufficient benefit). These thoughts will be directly evaluated and more helpful ideas developed. Furthermore, we will initially evaluate these thoughts using a technology, virtual reality (VR), which is inherently engaging and exciting. 2). Sedentary behaviour will be targeted in its own right, independently of exercise, in the intervention. 3). The intervention will be co-designed with patients. Study design and methods The research will involve three phases: 1) an understanding phase 2) a design phase and 3) a testing phase.1) Qualitative interviews will be conducted with patients who have schizophrenia, those who support patients at home, and healthcare staff. These interviews will focus both on exercise and sedentary behaviour, exploring what stops and what encourages each. 2) An intervention will be co-designed with patients, carers, and staff to create a shared solution. This will build on information from the interviews, a specific psychological theory that underlies the most powerful psychological treatments, and lessons from previous approaches. 3) The new intervention will be tested with 15 inactive people who have schizophrenia to see if it is possible and whether it may help to increase exercise and reduce sitting. Patient and public involvement This project has been developed with the support of the McPin Foundation, a charity that puts the involvement of people with lived experience of mental health problems at the heart of research methods and the research agenda. Thirty people with lived experience of schizophrenia have helped shape this research project, and during the research the intervention will be designed jointly (co- designed) with patients. Dissemination If the intervention is potentially helpful then the next step will be a rigorous randomised controlled clinical trial. Adoption into the NHS will be more likely as both NHS patients and staff will have been involved in the intervention design.

Research activity codes: 6.7 PHYSICAL
Health categories: MENTAL HEALTH