Physical activity in psychiatry: Current state and challenges
An online-survey on sports psychiatry in health professionals
Abstract
Abstract:Introduction: Physical activity (PA) shows beneficial effects for various mental illnesses, but exercise-prescription has not yet become routine practice in psychiatry. Therefore, this survey addresses attitudes and barriers towards exercise-prescription in health professionals. Methods: We conducted an anonymous online-survey among health professionals on the importance of PA in prevention and treatment of mental illness and perceived barriers as part of a larger survey on sports psychiatry. The survey was promoted by societies for sports psychiatry. Results: N = 310 health professionals from Switzerland (86.5%) and other countries responded to the online survey. Sixty percent were physicians (51.1% psychiatrists). Most respondents strongly agreed that PA plays an important role in prevention and treatment of mental (80.2%, 69.8%) and physical (84.5%, 72.0%) illness. Forty-six percent use PA in prevention and 59.4% in treatment of mental illness with lower proportions for physical illness (39.5%, 36.2%). Most mentioned barriers to the use of PA were “insufficient possibilities” in psychiatric institutions (34.8%) and “no reimbursement” (41.9%) in private practice. Participants working in private practice rated barriers in practice significantly higher than those from other workplaces. “No motivation” was found to be the most common barrier for patients (56.5%). PA was used most often for depression (39.5%) followed by substance use disorders (32.1%) and anxiety disorders (30.9%). Conclusions: Health professionals in Switzerland and some extent other European countries show a positive attitude towards the use of PA in mental illness. Current barriers, especially reimbursement in private practice should be addressed to improve prescription-rates of PA.
Introduction
In addition to its general positive effects on mental wellbeing [1], physical activity (PA) has been shown to have beneficial effects for various mental illnesses such as depression [2], anxiety [3], schizophrenia [4], dementia [5] and addiction [6]. In the context of increased cardiovascular morbidity in patients with mental illnesses [7], PA has the potential to mitigate cardiovascular and metabolic risk factors which further underlines its importance in treatment regimens [8, 9]. Whereas exercise prescription is common practice and recommended with high evidence levels in somatic illness such as heart failure [10], psychiatric guidelines started to include PA only in recent years: The World Federation of Societies for Biological Psychiatry (WFSBP) recently has published guidelines recommending to incorporate life-style factors such as PA as a foundational component in clinical practice for adults with major depressive disorder [11]. The most recent German treatment-guidelines for unipolar depression propose a strong recommendation to apply structured exercise and increase PA in patients with depression [12]. While PA is acknowledged as efficacious in treatment of various psychiatric diagnoses with clinical guidelines increasingly recommending it for treatment, its widespread prescription is not yet a reality. This situation stems from various factors, but notably, the perspectives of health professionals are crucial in identifying potential obstacles to prescribing PA. Hence, the aim of this paper is to assess opinions of health professionals on the significance of PA in mental illnesses.
A small number of publications has addressed the implementation of PA programs in psychiatry: A survey in a tertiary care medical center in the United States of America (US) [13] found that more than half of the service providers recommended exercise as part of psychiatric treatment but only 30% followed US national guidelines. Two surveys in German speaking countries: (1) across 48 psychiatric hospitals in German speaking Switzerland [14] and (2) among 4 German psychiatric university hospitals [15] found that all hospitals provided PA and exercise therapies with 97% of the Swiss hospitals even providing specific sports therapy. Participation rates of patients in PA and exercise therapies were similarly low with (1) 25% and (2) 23% of hospitalized patients. While 23–25% might seem a substantial proportion, given the cost-effectiveness and broad health-benefits of PA, a higher percentage would be expected. To facilitate exercise prescription and increase participation-rates in exercise programs health professionals expressed the need of specific vocational training and improvement of knowledge on beneficial effects of PA for mental health [13, 14]. The authors of the German survey concluded that due to high heterogeneity of participation-rates across the surveyed hospitals, structural factors such as an increase of exercise programs might play an important role for participation-rates [15].
Another factor hindering participation in exercise programs are perceived barriers within patients with psychiatric illness: An Australian survey among nurses [16] found a positive attitude towards exercise prescription in patients with mental illness despite perceived barriers of patients due to their psychiatric symptoms. A higher rate of exercise-prescription was associated with perceiving less barriers to exercise in mentally ill patients and organizational structures. The nurses’ perception of patient-barriers aligns with findings in a qualitative survey among patients with severe mental illness. The most frequently mentioned barriers in the survey included the adverse effects of psychiatric medication, psychiatric symptoms, and concurrent physical comorbidities [17]. A meta-analysis of 12 studies of barriers to exercise within psychiatric patients [18] found “low mood” and “stress” followed by “lack of support” as most prevalent barriers.
Taken together there is still a need for information on the views of health professionals on the usefulness of PA in psychiatric clinical practice including barriers to increased exercise-prescription and participation in exercise programs.
Based on these findings, the Swiss Society for Sports Psychiatry and -psychotherapy (SSSPP) conducted an online-survey among health professional within Switzerland and other European countries. Our main question was to assess the perceived importance of PA in physical and mental illnesses and to detect barriers towards its implementation. Based on previous findings, we hypothesized that (1) the perceived importance of PA is higher in prevention and treatment of physical illness compared to psychiatric illness. For more exploratory purposes we additionally hypothesized that (2) the lack of reimbursement by health insurances is the most common barrier to exercise prescription in outpatient care, and (3) health professionals in private practice rate barriers to PA prescription in their setting significantly higher than others.
Methods
To acquire a first-hand opinion about sports psychiatry from health professionals, an anonymous online survey was conducted.
Procedure
Participants were recruited between February 1 and November 9, 2022 on a broad scope, namely: The Swiss, German, Austrian and international Societies of Sports Psychiatry and -psychotherapy, the Section for Sports Psychiatry (“Referat für Sportpsychiatrie”) of the German Society for Psychiatry and Psychotherapy (DGPPN) as well as the Swiss Society of Sports Physiotherapy promoted the survey via e-mail, websites, newsletters, and social media (i.e. Twitter, LinkedIn) and by member’s personal networks. The editorial board of the Journal “Sports Psychiatry” and all the authors of the first German textbook of sports psychiatry [19] were contacted and asked to spread the survey within their networks. In addition, child and adolescent psychiatrists, psychiatrists, and general practitioners in Switzerland were invited through local physician networks and during educational sessions by board members of the SSSPP. There was no financial compensation for the participants. The survey was offered in German and English. The original German questions were translated into English by the last author and reviewed by all authors.
Questionnaire
The questionnaire was drafted, reviewed and pre-tested by three SSSPP board members. The original questionnaire consisted of 6 parts covering several independent aspects of sports psychiatry. Other parts of the questionnaire have been published elsewhere [20]. The results presented here are only a part of the complete online survey; they cover sample characteristics, the questions on importance of PA in prevention and treatment of mental illness and associated challenges. The full questionnaire covered in this paper is accessible as Electronic Supplementary Material (ESM 1).
Sample characteristics: Age-range, gender, country of residence, vocational training, medical specialty (physicians only), workplace, awareness of sports psychiatry. PA in prevention and treatment: Four questions on importance of PA in prevention and treatment of physical and mental illness (5-level Likert scale: “strongly disagree” to “strongly agree”). In which diagnoses is PA used for treatment (List of categories as presented in Table 2). Barriers: Perceived barriers to the use of PA in psychiatric treatment for psychiatric institution, private practice, patients’ perception in the view of health professionals. One open question: “additional barriers”. The barriers items were developed according to previously published studies [13–16, 18] and clinical experience of the authors.
Data Collection and Analysis
Data were collected through a REDCap-based online survey hosted at the Psychiatric University Hospital Zurich and University of Zürich, Switzerland [21, 22]. If participant information were missing, the respondent was excluded from the analysis. Only complete datasets of the subsequent parts of the questionnaire were used for the analysis. Thus, the number of answered parts of the questionnaire varies.
Participants provided informed consent for participation in this survey; no research ethics committee approval was necessary, since the data were collected anonymously, did not include health related data and no identifying information.
Results are displayed descriptively (number and percentage of respondents). Although the aim of this paper was to describe the data of the survey, we checked for differences between professions, medical specializations, and workplace. Due to limited responses from countries other than Switzerland, we decided not to calculate statistics for differences between countries. The Pearson’s χ2-test was used to check for differences in answers. A two-sided p > .05 was considered statistically significant. If no differences were found, data were presented as such, and non-significant p-values were not mentioned in the results. Analysis was carried out with IBM SPSS (Version 24).
Results
Sample-description
A total of n = 310 (50.3% female) health professionals responded to this online survey. The vast majority resided in Switzerland (n = 268, 86.5%). Thirty-six respondents (11.6%) lived in other European countries and n = 6 (1.0%) outside Europe. The largest proportion of respondents consisted of physicians (n = 186, 60.0%) followed by psychologists (n = 45, 14.5%) and various other university-trained professions such as sports-scientists or physiotherapists (n = 39, 12.6%). Of the physicians n = 95 (51.1%) were specialists for adult psychiatry. More than half of respondents were aware (n = 149, 48.1%) or partly aware (n = 44, 14.2%) of sports psychiatry as a field of psychiatry. For more details on the sample see Table 1.
PA in prevention and treatment
N = 232 answered questions on the role of PA in prevention and treatment. Most respondents strongly agreed that PA plays an important role in the prevention of physical (n = 196, 84.5%) and mental (n = 186, 80.2%) illness. As for its use in treatment a smaller but still substantial proportion strongly agreed with PA playing an important role in physical (n = 167, 72.0%) and mental (n = 162, 69.8%) illness. Almost no respondents disagreed or strongly disagreed with PA playing an important role in either prevention (mental illness n = 3, 0.9%; physical illness n = 2, 0.6%) or treatment (mental illness n = 3, 0.9%; physical illness n = 2, 0.6%).
Of the n = 276 respondents who were clinically active more than half (59.4%) use PA for treatment and 46.0% in prevention of mental illness. A smaller proportion uses PA for treatment (36.2%) and prevention (39.5%) of physical illness. Twenty-four respondents (8.7%) do not use PA in their clinical practice.
Use of PA according to diagnosis
Eighty-one respondents gave information on their use of PA in various diagnoses. As shown in Table 2, respondents used PA in the treatment of depression (n = 32, 39.5%) most often followed by substance use disorders (n = 26, 32.1%) and anxiety disorders (n = 25, 30.9%). On the other end of the scale eating disorders (n = 10, 12.3%) and mania and bipolar disorders (n = 10, 12.3%) were mentioned least often.
Barriers to prescribing and implementing PA
Within psychiatric institutions, most frequently mentioned barriers to including PA into psychiatric treatment were “no or insufficient access to exercise therapies” (n = 108, 34.8%) and “lack of exercise-infrastructure” (n = 99, 31.9%). A smaller proportion of respondents mentioned “no knowledge” (n = 81, 26.1%) or “no understanding” (n = 62, 20.0%) of beneficial effects of PA in psychiatry. In private practice the most common barrier was the lack of reimbursement of PA interventions (n = 130, 41.9%) and missing ways to prescribe PA (n = 104, 33.5%). “Lack of exercise-infrastructure” and “no or insufficient access to exercise therapies” were mentioned by a similar proportion as for psychiatric institutions (n = 102, 32.9%; n = 99, 31.9%). N = 13 respondents added opinions within the free-text answer that mainly reflected the results depicted above and yielded no additional insights.
Health professionals assumed that the main barriers to increasing PA for patients was the lack of motivation (n = 175, 56.5%) followed by “no social support” (n = 128, 41.3%) and “no knowledge” of positive effects (n = 124, 40.0%). “No understanding” as a barrier for patients was mentioned least often (n = 111, 35.8%).
The item “no barriers to PA prescription” was selected by n = 10 (3.2%).
Differences between groups
Table 3 shows χ2 values for all questions by vocational education, medical specialty, and workplace.
Role of PA in prevention and treatment
Significantly more respondents from private practice did not agree or strongly disagree that PA plays an important role in prevention (6.4%) and treatment (12.8%) of mental illness.
Barriers to PA
For barriers to PA in psychiatric institutions, students and physicians rated “Lack of exercise-infrastructure” and “access to exercise therapies” mor often as barriers; respondents from somatic medical specialties significantly more often mentioned “no understanding” (44.2%).
All barriers to prescribing PA in private practice were mentioned significantly more often by health professionals in private practice: “No reimbursement” (60.9%), “no ways to prescribe” (51.7%), “lack of infrastructure” (50.6%), and “no access to exercise therapies” (50.1%).
Regarding medical specialties, “no ways to prescribe” was most often mentioned by specialists in psychosomatic medicine (80.0%).
All patient barriers were selected by a significantly higher proportion of physicians compared to other professionals: “no motivation” (66.7%), “no social support” (50.0%), “no knowledge” (50.0%), and “no understanding” (43.5%).
A higher proportion of respondents in private practice selected “no motivation” (72.4%) and “no knowledge” (52.9%). Physicians in somatic disciplines more often chose “no understanding” (62.8%).
Discussion
Our survey among health professionals on the perceived role of PA in psychiatric treatment and barriers to its implementation reached a considerable number of respondents form the German speaking part of Switzerland and a small number from other, mainly European countries. Although the majority are physicians with a high proportion of psychiatrists, we reached respondents from a broad variety of professions and workplaces. Our results support the notion, that health professionals believe PA to be an important tool in prevention and treatment of physical and mental illness. The majority included PA into treatment of various psychiatric diagnoses, especially depression, substance use disorders, anxiety disorders, sleep disorders and ADHD. Contrary to our fist hypothesis, respondents rated the role of PA as equally important in mental and physical illness.
Regarding the spectrum of diagnoses that are treated with PA by respondents, this seems to be partially in line with the current body of evidence and levels of recommendation in guidelines. There is a strong recommendation for the use of PA in unipolar depression [11, 12] and the current literature provides positive meta-analyses in substance-use [6] and anxiety disorders [23] that are limited by high risk of bias due to heterogenous studies and methodological concerns. Despite growing evidence of beneficial effects of PA as addon treatment to antipsychotic medication in patients with schizophrenia on cognitive symptoms [24], positive and negative symptoms, depressive symptoms and quality of life [4], PA is still scarcely used in schizophrenia-treatment which might reflect motivational challenges due to the severity of the disease and lacking knowledge. Our finding of rare prescription of PA in eating disorders and mania is supported by evidence that PA should be managed with caution in eating disorders [25] and mania [26].
We found barriers to increased PA prescription in psychiatry to be more common in private practice than in institutions. Supporting our hypothesis, the lack reimbursement of PA interventions was the main barrier for private practice, followed by ways to prescribe PA. As hypothesized (hypothesis 2), reimbursement was the barrier most often mentioned and (hypothesis 3) professionals in private practice rated barriers in private practice significantly higher than respondents from other workplaces.
Our findings suggest that optimizing access to therapies including PA and providing sufficient infrastructure could facilitate the use of PA during psychiatric treatment. This contrasts with previous results from Escobar-Roldan and coworkers that described insufficient knowledge and training as the most common barrier to PA prescription [13]. Possibly, by ongoing educational activities regarding effects of PA in mental health in Switzerland [27] and internationally [28], a higher degree of knowledge on beneficial effects of PA has been achieved.
Health professionals in private practice significantly more often mentioning various barriers for PA prescription might reflect their clinical everyday-experience and reduced awareness of professionals working in other sectors regarding the limitations of PA prescription for outpatients especially in private practice. The problem of reimbursement was also addressed by Chekroud and Trugerman [29], who made an important point by stating, that this might implicitly suggest that exercising was less worthwhile than other treatment-modalities such as psychotherapy and medication. Our finding that respondents from private practice showed a slightly but significantly lower agreement with the role of PA in prevention and treatment of mental illness might at least partially be influenced by this notion.
Inpatients in Swiss psychiatric clinics are likely to meet the recommended weekly PA (150 minutes of moderate or 75 minutes of vigorous PA) during their treatment [30]. However, the levels of PA drastically decrease 6 weeks after discharge from inpatient treatment for depression [31]. Therefore, the transfer of structured PA to subsequent outpatient treatment poses a challenge that is reflected by our finding of increased barriers to PA-prescription in private practice especially regarding reimbursement. Hoffman et al. [32] found that PA levels did not differ between the PA group and the inactive control group one year after a randomized controlled trial evaluating the effect of a PA program on depression while those patients who met recommended PA levels were more likely to show remission at follow-up.
Regarding patients’ barriers to PA, respondents seem to focus on lack of motivation and social support with still 40% who were of the opinion, that there is a gap in knowledge on patients’ side. Since those are the views of health professionals and not patients, this must be taken with a grain of salt. Nonetheless, the barrier most often mentioned was “no motivation”, reflecting aspects of common symptoms of mental illness such as impaired drive, fatigue, low mood, and anhedonia as well as side effects of psychotropic drugs. This is in line with results from studies among patients that found symptoms of mental illness and side effects of medication as most perceived barriers [17, 18]. These data support our finding that physicians rated patient barriers significantly higher than other professionals. Physicians more often treat more severely ill patients with more barriers towards PA, due to higher symptom load and higher frequency of pharmacological treatment. Additionally, health professionals in private practice rated the lack of motivation and knowledge of patients significantly higher, which could be associated with the higher motivational requirements to engage in PA in an outpatient setting.
The results from our study suggest various practical implications to facilitate PA for psychiatric patients: (1) Possibilities for PA-prescription in private practice and especially reimbursement of sports therapists by insurance companies should be targeted by specific initiatives. Therapeutic approaches should be tailored to the specific needs of people with mental illness, such as motivational barriers and ease of access. To gain more knowledge on patients’ barriers a survey among patients would yield better results that could assist designing specific interventions. (2) More recent data and an in-depth analysis of current barriers to the use of PA in psychiatric institutions in Switzerland would be helpful to propose concrete approaches to increase the use of PA on a national level. (3) to address the gap between sufficient PA during inpatient treatment and the outpatient setting, PA counselling programs tailored for this specific group could be helpful. (4) Educational activities for medical professionals within established educational structures may have the potential to increase knowledge about beneficial effects of PA in mental illness and hereby lay the ground to strengthen the use of PA in clinical practice.
A current trial is investigating the effects of a PA counselling program delivered for 12 months after discharge in inpatients with depression. First results found that participants showed a significantly lower reduction of daily step-counts 6 weeks after discharge [31]. Future research should focus on the feasibility, acceptability, cost-effectiveness, and efficacy of PA programs for outpatients. Evidence for concrete programs including their cost-effectiveness could strengthen discussions with insurance companies and policy makers, facilitating the development of reimbursement models for PA treatment in psychiatry. Additionally, there is still a high need of methodologically sound studies with larger sample sizes on effects of PA in the treatment of mental illness other than unipolar depression to formulate recommendations for psychiatric practice.
Strengths and limitations
To our knowledge this is the first survey on sports psychiatry among Swiss and some European professionals including their views on the use of PA in psychiatry. Its findings are a valuable addition to the still scarce body of evidence on viewpoints and barriers concerning exercise-prescriptions in psychiatric treatment. The survey includes a variety of health professionals engaged in psychiatric practice but is strongly biased towards psychiatrists. Therefore, it does not consist of a representative sample of health professionals and the findings should be considered as exploratory. Furthermore, due to the open recruitment process, we were not able to define specific response rates which might lead to a biased sample. Reporting findings from a larger questionnaire aiming at various aspects of sports psychiatry might lessen the weight of our data.
Although our survey has reached a decent number of respondents from Switzerland, we reached only limited response from various other countries. Therefore, our results from respondents outside of Switzerland are of anecdotal value. Since the survey was distributed by sports psychiatric societies, there is a high probability of selection bias leading to more favorable views on effects of PA in mental illness compared to physical illness than in the whole population of health professionals. Not having included a French version of the questionnaire, the survey omits cultural nuances between Swiss language-regions. Regarding barriers to prescribing PA, the approach focusing mainly on multiple-choice, the answers of participants might have been biased. A qualitative approach might have yielded more concrete information. Also, Patient-barriers rated by professionals and not patients themselves do not necessarily reflect patient perspective. Finally, there is a methodological limitation due to translation of the original German questionnaire into English by the authors without a validation process, decreasing the validity of responses from the English questionnaire.
Conclusions
Health professionals in Switzerland and to some extent in other European countries show a positive attitude towards the use of PA in prevention and treatment of mental illness. However, addressing institutional barriers such as possibilities and infrastructure as well as reimbursement of PA interventions and established possibilities for exercise-prescriptions for outpatients might foster the regular use of PA in the treatment of psychiatric illness. Those fields should be targeted through educational and clinical initiatives by sports psychiatric societies in cooperation with health insurances, policy makers and other professional organizations such as sports therapists. Further research is needed on ways to increase PA of psychiatric patients in a sustainable way and on more detailed analyses of institutional possibilities for outpatients and inpatients as well as patients’ barriers to PA.
Electronic Supplementary Materials
The following electronic supplementary material is available with this article at https://doi.org/10.1024/2674-0052/a000069
References
1 Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: A cross-sectional study. Lancet. Psychiatry. 2018;5:739–46. https://doi.org/10.1016/S2215-0366(18)30227-X
2 , Physical activity for the treatment and prevention of depression: A rapid review of meta-analyses. Dtsch Z Sportmed. 2021;72:280–7. https://doi.org/10.5960/dzsm.2021.499
3 . Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Serv Res. 2018;18(559). https://doi.org/10.1186/s12913-018-3313-5
4 . Exercise improves clinical symptoms, quality of life, global functioning, and depression in schizophrenia: A systematic review and meta-analysis. Schizophr Bull. 2016;42(3):588–99. https://doi.org/10.1093/schbul/sbv164
5 . The benefits of exercise and metabolic interventions for the prevention and early treatment of alzheimer’s disease. Curr Alzheimer Res. 2017;14(1):47–60. https://doi.org/10.2174/1567205013666160819125400
6 . Impact of physical exercise on substance use disorders: A meta-analysis. PLoS One. 2014;9(10):e110728. https://doi.org/10.1371/journal.pone.0110728
7 Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: A large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 2017;16(2):163–80. https://doi.org/10.1002/wps.20420
8 Cardiovascular disease and excess mortality among people with depression: Meta-analytic evidence and the potential role of physical activity as a game changer. Dtsch Z Sportmed. 2021;72. https://doi.org/10.5960/dzsm.2021.498
9 European guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315–81. https://doi.org/10.1093/eurheartj/ehw106
10 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200. https://doi.org/10.1093/eurheartj/ehw128
11 , Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World federation of societies for biological psychiatry (wfsbp) and australasian society of lifestyle medicine (aslm) taskforce. World J Biol Psychiatry. 2022;1–54. https://doi.org/10.1080/15622975.2022.2112074
12 . Nationale versorgungsleitlinie unipolare depression – leitlinienreport, version 3.0.2022 [cited 2023 05–15].
13 . Exercise prescription practices to improve mental health. J Psychiatr Pract. 2021;27(4):273–82. https://doi.org/10.1097/pra.0000000000000554
14 The current state of physical activity and exercise programs in german-speaking, swiss psychiatric hospitals: Results from a brief online survey. Neuropsychiatr Dis Treat. 2016;12:1309–17. https://doi.org/10.2147/NDT.S107313
15 Angebot und inanspruchnahme von sporttherapie in psychiatrischen kliniken in deutschland. Der Nervenarzt. 2020;91(7):642–50. https://doi.org/10.1007/s00115-019-0782-7
16 . Barriers to exercise prescription and participation in people with mental illness: The perspectives of nurses working in mental health. J Psychiatr Ment Health Nurs. 2015;22(6):440–8. https://doi.org/10.1111/jpm.12205
17 . Barriers to exercise among people with severe mental illnesses. Psychiatr Rehabil J. 2013;36(1):45–7. https://doi.org/10.1037/h0094747
18 . Motivating factors and barriers towards exercise in severe mental illness: A systematic review and meta-analysis. Psychol Med. 2016;46(14):2869–81. https://doi.org/10.1017/s0033291716001732
19 . Lehrbuch der Sportpsychiatrie und -psychotherapie: Psychische Gesundheit und Erkrankungen im Leistungssport. Hogrefe; 2022
20 . Sports psychiatry: Discipline, areas of activity, collaboration, and training: Results of a survey of german speaking professionals on sports psychiatry. Sports psychiatry. 2022;1(3):90–9. https://doi.org/10.1024/2674-0052/a000022
21 . Research electronic data capture (redcap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010
22 The redcap consortium: Building an international community of software platform partners. Journal of biomedical informatics. 2019;95:103208. https://doi.org/10.1016/j.jbi.2019.103208
23 An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. 2017;249:102–8. https://doi.org/10.1016/j.psychres.2016.12.020
24 Aerobic exercise improves cognitive functioning in people with schizophrenia: A systematic review and meta-analysis. Schizophrenia Bulletin. 2017;43(3):546–56. https://doi.org/10.1093/schbul/sbw115
25 . How to address physical activity and exercise during treatment from eating disorders: A scoping review. Curr Opin Psychiatry. 2023;36(6):427–37. https://doi.org/10.1097/yco.0000000000000892
26 Association of exercise with quality of life and mood symptoms in a comparative effectiveness study of bipolar disorder. J Affect Disord. 2013;151(2):722–7. https://doi.org/10.1016/j.jad.2013.07.031
27 . Positionspapier–körperliche aktivität und psychische gesundheit. Swiss Arch. Neurol. Psychiatry Psychother. 2021;172(3):w03199.
28 Epa guidance on physical activity as a treatment for severe mental illness: A meta-review of the evidence and position statement from the European Psychiatric Association (EPA), supported by the International Organization Of Physical Therapists In Mental Health (IOPTMH). Eur Psychiatry. 2018;54:124–44. https://doi.org/10.1016/j.eurpsy.2018.07.004
29 . The opportunity for exercise to improve population mental health. JAMA Psychiatry. 2019;76(11):1206–7. https://doi.org/10.1001/jamapsychiatry.2019.2282
30 Psychiatric in-patients are more likely to meet recommended levels of health-enhancing physical activity if they engage in exercise and sport therapy programs. Front Psychiatry. 2018;9:322. https://doi.org/10.3389/fpsyt.2018.00322
31 Short-term outcomes of physical activity counseling in in-patients with major depressive disorder: Results from the pacinpat randomized controlled trial. Front Psychiatry. 2023;13:3074–111. https://doi.org/10.3389/fpsyt.2022.1045158
32 Exercise and pharmacotherapy in patients with major depression: One-year follow-up of the smile study. Psychosom Med. 2011;73(2):127–33. https://doi.org/10.1097/PSY.0b013e31820433a5
