Results suggest that mild to moderate aerobic exercise is an effective programme for decreasing psychiatric symptoms and for increasing QOL in patients with schizophrenia.
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Results suggest that mild to moderate aerobic exercise is an effective programme for decreasing psychiatric symptoms and for increasing QOL in patients with schizophrenia.
Results suggest that mild to moderate aerobic exercise is an effective programme for decreasing psychiatric symptoms and for increasing QOL in patients with schizophrenia.
The effects of physical exercises to mental state and
quality of life in patients with schizophrenia
A . A . A C I L 1 ms n , S . D O G A N 2 p h d & O . D O G A N 3 md 1 Psychiatric Nurse Practitioner (Msn), Psychiatric Department, and 2 Professor, Department of Psychiatric Nursing, School of Nursing, and 3 Professor, Department of Psychiatry, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey ACIL A. A., DOGAN S. & DOGAN O. (2008) Journal of Psychiatric and Mental Health Nursing 15, 808815 The effects of physical exercises to mental state and quality of life in patients with schizophrenia The purpose of this study was to examine the effects of 10 weeks of physical exercises programme on mental states and quality of life (QOL) of individuals with schizophrenia. The study involved 30 inpatients or outpatients with schizophrenia who were assigned randomly into aerobic exercise (n = 15) group and control (n = 15) group, participated to the study voluntarily. There were no personal differences such as age, gender, disorder duration, medication use between the both groups. An aerobic exercise programme was applied to the subject group, the periods of 10 weeks as 3 days in a week. Data were collected by using the Brief Symptom Inventory, the Scale for the Assessment of Positive Symptoms, the Scale for the Assessment of Negative Symptoms and to the both group before and after the exercise programme. After the 10-week aerobic exercise programmes the subjects in the exercise programme showed signicantly decreases in the Scale for the Assessment of Positive Symptoms, the Scale for the Assessment of Negative Symptoms and the Brief Symptom Inventory points and their World Health Organization Quality of Life Scale-Turkish Version points were increased than controls. These results suggest that mild to moderate aerobic exercise is an effective programme for decreasing psychiatric symptoms and for increasing QOL in patients with schizophrenia. Keywords: negative symptoms, physical exercise, positive symptoms, quality of life, schizophrenia Accepted for publication: 2 July 2008 Correspondence: O. Dogan C.U. Hastanesi Psikiyatri ABD TR58140 Sivas Turkey E-mails: ordogan@gmail.com; odogan@cumhuriyet.edu.tr Introduction Recently, there has been a growing interest on the role of physical exercise in the enhancement of physical and mental health. The studies shows that physical activity affects individuals physical functions in a positive way, decreases morbidity risk of many illnesses, such as coroner hearth disease, hypertension, stroke, type 2 diabetes melli- tus, certain cancers, osteoporosis, obesity, and also contri- butes positively to many physical illness treatments (Pierce et al. 1993, Salmon 2001, Schmitz et al. 2004). Several studies on the relationship of physical activity and mental health showed that physical activity improves mental health status especially had a positive effect on depres- sion, anxiety and mental well-being (Moses et al. 1989, Babyak et al. 2000, Mather et al. 2002, Dogan et al. 2004, Schmitz et al. 2004). Also some studies have reported that regular physical exercise programmes had a positive effect on psychiatric disorders such as anxiety disorders, depres- sion, schizophrenia, somatoform disorders, dementia and Journal of Psychiatric and Mental Health Nursing, 2008, 15, 808815 808 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd substance abuse (Veale et al. 1992, Palleschi et al. 1996, Thachuk & Martin 1999, Daley 2002, Schmitz et al. 2004). There are several studies involving patients with clinical depression and anxiety but no enough controlled experimental studies showing the effects of physical exercises on psychiatric disorders especially treatment and rehabilitation of patients with schizophrenia. Schizophrenia is a disorder characterized by a very broad range of psychiatric symptoms and is dened by a group of characteristic of positive or negative symptoms: deterioration in social, occupational or interpersonal rela- tionships. Schizophrenia is typically viewed as a chronic disorder that has a poor long-term outcome (Andreasen & Black 2001). This situation may lead poorly quality of life (QOL) of patients with schizophrenia. Schizophrenic people suffer a signicantly poorer standard of living than others in the community do. In some studies, it has been determined that the QOL of patients with schizophrenia was low than normal population (Katscihnig 2000, Pinikahana et al. 2002, Chan & Yu 2004). A few no controlled experimental studies showed that physical exercise has positive effects in patients with schizophrenia (Pelham & Campagna 1991, Faulkner & Biddle 1999, Thachuk & Martin 1999, Matthew & Wattles 2001). In case reports, it was determined a decrease on depressive and psychotic symptoms and psychomotor agitations but increase on social skills of patients with schizophrenia (Chamove 1986, Pelham & Campagna 1991, Faulkner & Sparkes 1999, Thachuk & Martin 1999). Pelham and Campagna investigated the physiologi- cal, psychological and social effects of exercise in 40 out- patients with schizophrenia (Pelham & Campagna 1991). Their results indicated decreased in depressive symptoms, increased general well-being and improved physical tness. Antipsychotic drugs that are mainly used in schizophrenia treatment causes decrease in relapses and hospitalizations of patients with schizophrenia, but they cannot prevent deterioration of social functionalities and QOL, impair- ment of cognitive functions, job loss or decrease in work efcacy. Besides, antipsychotic drugs have many extrapy- ramidal and autonomic side effects. In addition, necessity of long medication period and high medicine costs may cause patient unable to use those medicines regularly (Dogan et al. 2004). For those reasons, researchers indicate that not only medication therapy itself can be sufcient but also several treatment methods should be used in integrity. In the literature, as positive effects of physical exercises in patients with schizophrenia are indicated, needs for those types of controlled studies on this subject are also empha- sized due to especially the insufciency of performed con- trolled studies on this subject (Artal & Sherman 1998, Thachuk & Martin 1999). This study has been carried out in order to show the effect of regular physical exercises programme that was performed in a manner of 40 min daily, 3 days in a week and for 10 weeks long on mental states and QOL of outpatients with schizophrenia. Methods Participants This study was a quasi-experimental type and was per- formed in a psychiatry clinic of a university hospital located in Central Anatolia region of Turkey. Sampling of the research consists of 30 patients (15 subjects, 15 con- trols), who had hospitalized upon the schizophrenia diag- noses made according to Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, who were discharged from the hospital and followed up as outpatients between 1992 and 2005. The patients (subjects and controls) lived in Sivas province had similar characteristics in age, gender, disorder symptoms, and accepted to participate in the study. Individuals, which matched all necessary criteria, were divided by means of randomization method into two groups as one being the subject group and the other being control group. All of participants (subjects and controls) were used to antipsychotic drugs at the time of the exercise programme. Besides this, subjects (inpatients) have been participated in group psychotherapy. Questions are: 1. Is there a difference between the Scale for the Assess- ment of Positive Symptoms points of patients with schizophrenia who participate in regular physical exer- cise and who do not? 2. Is there a difference between the Scale for the Assess- ment of Negative Symptoms points of patients with schizophrenia who participate in regular physical exer- cise and who do not? 3. Is there a difference between the Brief Symptom Inven- tory points of patients with schizophrenia who partici- pate in regular physical exercise and who do not? 4. Is there a difference between the World Health Organi- zation Quality of Life Scale (WHOQOL) points of patients with schizophrenia who participate in regular physical exercise and who do not? Instruments Data were collected by means of following: The Scale for the Assessment of Negative Symptoms (SANS): SANS measures the level, distribution and severity change of negative symptoms. The scale was developed by Derogatis (1993). The validity and reliability studies in Physical exercises in schizophrenia 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 809 Turkey were done (Erkoc et al. 1991a). Its Cronbachs alpha internal consistency was 0.93. It is a Likert type scale including ve subscales and 25 items, having a score range of 05. Those subscales investigate affective atting or blunting, alogia, apathy-avolition, anhedonia-asociality and attention. Total points vary between 0 and 125. The Scale for the Assessment of Positive Symptoms (SAPS): SAPS also measures the level and distribution of the positive symptoms of the patients and was developed by Andreasen (1990). Its validity and reliability studies for Turkey were performed (Erkoc et al. 1991b). Its Cron- bachs alpha internal consistency was 0.82. It is a Likert type scale including four subscales and 34 items having score range of 05. Those subscales were delusions, hallu- cinations, bizarre behaviour and positive formal thought disorder and inappropriate affect. Total points vary between 0 and 170. The Brief Symptom Inventory (BSI): BSI was used to assess psychiatric symptoms of the patients before and after the physical exercise programme. BSI was developed by Derogatis (1993) and adapted to Turkish by Sahin & Durak (1997). Its Cronbachs alpha internal consistency was 0.95. It is an inventory Likert type consisting of totally 53 items and nine subgroups, having score range of 04. Its point range is 0212. The higher the total points show that the symptoms of patient are the more severe. World Health Organization Quality of Life Scale- Turkish Version (WHOQOL-BREF-TR): World Health Organization developed WHOQOL in 1997. This scale, development simultaneously by 15 academic centres worldwide under the auspices of the World Health Orga- nization, consists of the 26 items divided into four broad domains: physical health, psychological health, social rela- tions and environment and two questions relating to the persons general perception of his/her QOL (general). For Turkey, the validity and reliability studies of the scale were done by Fidaner et al. (1999). Its Cronbachs alpha internal consistency was 0.86. Procedures The forms were applied in consecutive order to all the patients before the exercise programme begins. Physical exercise programme was applied in-group to the subjects for 10 weeks, as 3 days in a week and 40 min/day. The exercise programme was designed by the contribution of sport and physical education experts in a way as easing its practicing by the patients themselves in their daily life. Aerobic exercise was applied rst 2 weeks as 25 min/day in order to prevent its overdoing by the patients. Each exercise session began regularly with 10 min of limber up gures, and then continued with 25 min of aerobic exer- cises. Each programme session ended with 5-min cooling down gures. Heart beat rates of individuals were mea- sured before and after the each exercise session. In order to prevent overdoing, attention was paid for not to exceed the maximum pulse rate determined by using the 220-age formula. The scales were applied to the patients in both groups after the 10-week programme was completed. Data analysis The standard spss program was used in all statistical analysis. Chi-square test was used for comparison of the patients descriptive characteristics and Wilcoxon two matched sample test was used for assessment of the differ- ences between the scale average points of patients obtained before and after the physical exercise programme within the same group. Results The demographic and health characteristics of subject and control groups were similar. Patients being the age of 2145, the mean age of subject group was 32.06 years and that of control group was 32.66 years, and both of the groups the majority (60%) were male. 86.7% of the subject group and 73.3% of the control group were unemployed. Average disorder duration of patients in the subject group was 10.93 years and that of patients in the control group was 9.60 years (P > 0.05). In the subject group 80% of the patients and in the control group 93.7% of the patients used to take their medicines regularly (P > 0.05). It is determined that SAPS overall mean points of the subject group were 18.20 11.79 before the exercise pro- grammes and after 10-week exercise programmes it was 11.20 8.02, and the difference between those values was statistically signicant (P < 0.05). On the other hand, SAPS overall mean points of the control group were found to be as 16.46 18.55 before the exercise programme and was found to be 15.46 11.31 after the 10-week exercise pro- grammes, and it was stated that the differences between those values were not statistically signicant (P > 0.05). As a result of the comparison performed on the SAPS sub- groups mean points of the subject group obtained before and after the 10-week exercise application, it was found that illusions, delirium, hallucinations showed a statisti- cally signicant decrease after the programme (P < 0.05), and it was also determined that the mean points on bizarre behaviour and positive formal thinking impairment did not show any statistically signicant difference after the exer- cises (P > 0.05). However, no any statistically signicant difference was found in any subgroup mean points of the control group (P > 0.05) (Table 1). A. A. Acil et al. 810 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd The Scale for the Assessment of Negative Symptoms overall mean points of the subject group before the exercise were found to be as 25.60 17.25, and after the 10-week exercises programme, it was found to be as 15.20 12.28 and the difference between those values did not found to be statistically signicant (P < 0.05). On the other hand, SANS overall mean points of the control group before the exercise were found to be 32.20 17.70, and it was found to be 35.06 18.87 after the 10-week exercise period and the difference determined between those values was not found to be statistically signicant (P > 0.05). A statisti- cally signicant decrease (P < 0.05) was determined in all the subgroup mean points of the subject group related to the physical exercises except for the alogia subgroup mean points. However, there was no any statistically signicant difference for the any subgroup mean points of the control group (P > 0.05) (Table 2). The BSI overall mean points of the subject group were found to be 0.84 0.67 before the exercise and after the exercise application it was found to be 0.50 0.45, and the difference between those values was found statistically signicant (P < 0.05). However, while the BSI overall mean points of the control group before the exercise programme were found to be 0.78 0.75, it was found to be 0.98 1.23 after the 10-week exercise application, and the difference between those values was not considered to be statistically signicant (P > 0.05). Related to the physical exercise application, especially in somatization, interper- sonal sensitivity, anxiety disorder and hostility subgroups mean points and a statistically signicant decrease were found (P < 0.05); however, the difference in obsessive compulsive disorder, depression, phobic anxiety, paranoid thoughts, psychosis and additional items subgroups was not found statistically signicant (P > 0.05). The difference Table 1 The Scale for the Assessment of Positive Symptoms (SAPS) points of both patient groups before and after 10-week exercise programme Groups and Points Before the exercise programme Mean (SD) After the exercise programme Mean (SD) Test (Wilcoxon) P-value SAPS Subject group Overall points 18.20 (11.79) 11.20 (8.02) 3.06 <0.05 Illusions 7.33 (6.13) 3.86 (3.62) 2.29 <0.05 Hallucinations 5.26 (5.67) 3.80 (4.63) 2.77 <0.05 Bizarre behaviour 1.40 (2.87) 1.26 (2.01) 0.17 >0.05 Positive formal thinking impairment 3.20 (4.98) 2.26 (3.03) 0.63 >0.05 Control Group Overall points 16.46 (18.55) 15.46 (11.31) 0.74 >0.05 Illusions 5.00 (5.52) 4.93 (5.22) 0.21 >0.05 Hallucinations 5.26 (5.67) 6.26 (5.14) 1.15 >0.05 Bizarre behaviour 2.20 (3.29) 2.20 (3.46) 0.00 >0.05 Positive formal thinking impairment 3.13 (1.54) 1.40 (2.35) 1.70 >0.05 Table 2 The Scale for the Assessment of Negative Symptoms (SANS) points of both patient groups before and after 10-week exercise programme Groups and Points Before the exercise programme Mean (SD) After the exercise programme Mean (SD) Test (Wilcoxon) P-value SANS Subject group Overall points 25.60 (17.25) 15.20 (12.28) 3.29 <0.05 Emotional insensitivity 6.66 (4.54) 4.20 (2.78) 2.52 <0.05 Alogia 2.73 (3.17) 2.00 (2.23) 1.19 >0.05 Apathy 4.13 (4.08) 2.53 (3.31) 2.82 <0.05 Anhedonia 8.73 (6.26) 4.66 (4.62) 2.67 <0.05 Attention 3.40 (3.26) 1.80 (2.33) 2.68 <0.05 Control Group Overall points 32.20 (17.77) 35.06 (18.87) 0.28 >0.05 Emotional insensitivity 9.60 (7.66) 8.46 (4.29) 1.26 >0.05 Alogia 4.33 (3.71) 4.46 (4.29) 0.47 >0.05 Apathy 4.46 (3.31) 5.06 (3.41) 1.54 >0.05 Anhedonia 11.20 (5.32) 11.93 (4.83) 0.54 >0.05 Attention 5.53 (3.35) 5.13 (3.52) 1.19 >0.05 Physical exercises in schizophrenia 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 811 between subgroups mean points of the control group obtained before and after the programme was not found statistically signicant (P > 0.05) (Table 3). On the other hand, an increase was found in the WHOQOL-BREF-TR subgroups mean points of the subject group after the 10-week exercise programme and a statistically signicant increase was found especially in the points of physical and mental domains in relation to the physical exercise (P < 0.05); however, the increases of their mean points in social, environmental and cultural domains were not found statistically signicant (P > 0.05). The difference between WHOQOL-BREF-TR subgroup mean points of the control group before and after the programme was not found statistically signicant (P > 0.05) (Table 3). Discussion Our data show that the SAPS overall mean points, illusions and hallucinations subgroup mean points of the subject group decreased evidently after the 10-week physical exercise application. In some studies, a decrease in visual hallucination but an increase in personal self-respect and improvement in sleep quality in patients with schizophre- nia and also an improvement in their overall behaviours were observed at the end of the exercise programme (Chamove 1986, Faulkner & Sparkes 1999, Daley 2002, Challagan 2004). Yagi et al. (1992) stated that because of the increase in their activity level patients with schizophre- nia copy with their acute psychotic symptoms better than depressive patients. In our study, we found that the overall mean points and all subgroup points were signicantly decreased after the 10-week physical exercise application programme except alogia subgroup mean points that reect thinking impairment. Chamove (1986) stated that, after a regular physical exercise applied in patients with schizophrenia, negative symptoms of the schizophrenia such as body movement abnormalities, irritability, depressive mood, retardation and psychotic properties were diminished, and on the other hand, social interest, social skills and working capacity were improved related to the physical exercise. Lee et al. (1993) stated that in schizophrenia, as the increase in perceived threat, stress, tendency of being introverted arose, physical exercise remedied this with- drawal tendency by stimulating the patients interest in the outside world again. In many studies, emphasizes have been made on improvement of overall well-being, physical activity, self-condence and concentration in patients with schizophrenia provided by the aerobic exercise (Chamove 1986, Pelham & Campagna 1991, Faulkner & Sparkes 1999). This fact can be thought of as related to the exer- cise process and to the participation of the patients whose social relations had been limited due to the disorder, in a more active, amusing group activity by relieving them from their monotonous life and to the resultant increase in their social interactivity. On the other hand, no any signicant decrease was determined in the patients alogia subgroup mean points after the 10-week physical exercise programme (P > 0.05). Alogia is a concept related to the cognitive functions, describing a decrease in the amount of thoughts, impair- ments of verbal uency and productivity (Andreasen & Black 2001). The studies investigating the effect of physical exercise in patients with schizophrenia emphasize that Table 3 The Brief Symptom Inventory (BSI) and World Health Organization Quality of Life Scale-Turkish Version (WHOQOL-BREF-TR) points of both patient groups before and after 10-week exercise programme Groups and Points Before the exercise programme Mean (SD) After the exercise programme Mean (SD) Test (Wilcoxon) P-value BSI Subject group 0.84 (0.67) 0.50 (0.45) 2.66 <0.05 Control group 0.78 (0.75) 0.98 (1.23) 1.10 >0.05 WHOQOL-BREF-TR Subject group Physical domain 14.06 (2.05) 15.86 (2.23) 2.95 <0.05 Mental domain 13.66 (2.55) 15.73 (2.40) 3.16 <0.05 Social domain 11.20 (3.85) 12.53 (4.37) 1.01 >0.05 Environmental domain 14.73 (3.17) 15.53 (2.38) 1.26 >0.05 Cultural domain 14.33 (2.87) 15.33 (2.49) 1.53 >0.05 Control group Physical domain 13.73 (3.69) 14.46 (3.62) 1.42 >0.05 Mental domain 14.40 (4.15) 13.60 (3.81) 1.4 >0.05 Social domain 10.93 (4.83) 10.20 (4.09) 1.28 >0.05 Environmental domain 14.86 (2.77) 14.46 (1.92) 0.60 >0.05 Cultural domain 14.53 (2.66) 13.93 (1.79) 1.19 >0.05 A. A. Acil et al. 812 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd physical exercise has no effect on cognitive functions (Taylor et al. 1985, Faulkner & Biddle 1999, Daley 2002). After the 10-weekly physical exercise programmes, the BSI overall mean points and somatization, interpersonal insensitivity, anxiety disorder and hostility subgroup items mean points were found to be decreased. In schizophrenia, internal and external stress factors, social norms and family over control leads to anxiety in patients with schizophrenia. Daley (2002) is said that regular physical activity performed by patients with schizo- phrenia keeps them away from stressful stimuli by distract- ing their attention away from those stimuli and therefore helps to lessen their anxiety symptoms. Pelham & Campa- gna (1991) related to one-to-one case studies carried on with schizophrenia patients stated that aerobic exercise provided a decrement in fears, unimportant thoughts, anxiety and physical symptoms of anxiety but on the other hand it provided an increment in the concentration of patients with chronic schizophrenia. Patients with schizophrenia due to their disorders nature that causes suspicion and distrust feelings avoid their environment and become socially isolated (Fortinash & Holoday-Worret 1996). Pelham & Campagna (1991) mentioned limited communication atmosphere with their society of patients with schizophrenia and declared that those exercises established a social communication atmo- sphere in a group and that therefore they started to be interested in daily activities instead of keep returning into their inner world. It is thought that in relation to attention deciency, cognitive impairment, delirium, hallucinations, impaired reality perception causes interpersonal relations of patients with schizophrenia become more difcult, and that this problem might lead them to violent behaviours (Andreasen & Black 2001). Taylor et al. (1985) stated that physical exercise alleviates anger acutely and that it helps them to tolerate, for the long term, their feelings of being repressed. In our study, an evident decrease in somatization points of the patients was determined. The fact that the somati- zation points of the patients decreased after the application might be resulted from the decrease in their introverted mood state and from the increase of their ability to express themselves verbally better. An increase in WHOQOL-BREF-TR subgroup mean points of the subject group was determined after the physi- cal exercise programme and especially a signicant level of increase in their mental domain points was found depend- ing on the physical exercise. In the literature, it is stated that physical activity and regular physical exercise improve QOL of patients with schizophrenia mentally and psy- chologically (Faulkner & Sparkes 1999, Hutchinson et al. 1999, Mubarak et al. 2003, Chow et al. 2004). It was stated that physical exercise rather than helping patients with schizophrenia by means of diminishing their cognitive malfunctioning but diminished anxiety, depression and improved low self-condence improved QOL of patients only by arranging their environmental conditions (Faulkner & Sparkes 1999). Daley (2002) indicates that physical work capacity of psychotic individuals increases by means of physical activity, and that depending on the continuality of regular physical exercises, those individuals ensure their control over their weight and therefore they improve their self-respect and that those positive changes are reected on every aspects of their life. Physical exercise programme applied by patients with schizophrenia in the pattern of 10 weeks long as each session taking 40 min/day, provided a positive effect on QOL in patients with schizophrenia, and increased their QOL. Exercise programme provided a signicant improve- ment in points of physical domain consisting of overall physical activity and in points of mental domain consisting of emotions, cognitive functions and behaviours (P < 0.05). This fact also observed in their SAPS, SANS and BSI points that reects the symptoms of disorder. However, social, environmental and cultural domains that indicate QOL consist of the external factors that are out of individuals control. Therefore, it is considered as a normal fact that the application of those exercises individually without group- ing does not lead to the sufcient improvement in those domains. In our study, increase in positive symptoms and decrease in negative symptoms of the patients by means of physical exercise application might have provided a positive effect on improvement of their QOL. Therefore, it can be said that physical exercise makes a positive contribution to the QOL of patients with schizophrenia, and in case it is used in association with the other pharmacological and psychosocial treatment approaches, it may lead to much more signicant improvements mental states and QOL of patients. After the physical exercise programme, all of the participants have been stated that they have been more relaxed, untroubled, powerful and healthy. Some of them have been stated that they have been more active in daily activities in self-care. The patients were taking classical (haloperidol, u- phenazine decanoate) and atypical (risperidone, olanza- pine, quetiapine) antipsychotic agents (mean duration 10.26 7.59 years). We have not thought that the medi- cation used affected the scores on the instruments used in the study. On the contrary, physical exercise programme could be enhanced the treatment compliance and social interaction. Physical exercises in schizophrenia 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 813 Conclusion The results obtained in our study show that application of regular physical exercise practiced by patients with schizo- phrenia is a useful non-pharmacological application to improve their mental states and QOL. Nurses have an active role through the integrated approach in preventing disorders, their treatment and rehabilitation. For this reason, psychiatric nurses is an important group serving in encouraging inpatients to practicing physical exercise and after their discharging from hospital, serving in adapting those exercise applications in to daily living of patients (Speck 2002). Physical exercise programme is a new, cheap, effective, easily applicable and readily available method for which the available facilities would be sufcient as an alternative in supporting the therapy by signicantly effecting course of disorder both in clinical environment and after discharg- ing of those patients. For this reason, it is thought that in case it is used in integration with classical treatment methods, physical exercise would make positive contribu- tion to mental health and QOL of patients. Our results are very difcult to generalize because of we have been very limited amount of participant. This study being performed with limited time, long-term consequences of physical exercise has not been investigated. 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