Ecological monitoring of physical activity, emotions and daily life activities in schizophrenia: the DiAPAson study

Study setting

This cohort study was conducted in a subsample of sites involved in the Italian national DiAPAson project¹⁹: these include seven Departments of Mental Health (DMHs), one clinical research centre (IRCCS) and two RFs. DMHs recruited both outpatients and residential patients, while RFs only recruited residential patients.

Eligibility criteria and recruitment

From October 2020 to October 2021, 137 eligible patients (79 residential patients, 58 outpatients) and 113 healthy controls (matched for age and sex) were initially recruited at the 10 participating centres for ecological monitoring. Inclusion and exclusion criteria are reported in online supplemental materials. Online supplemental figure 1S shows in detail the sampling selection process. To ensure a balanced comparison, healthy controls were sampled using a combination of public advertisements and snowball sampling techniques and matched with the clinical sample based on sex and age group, defined as: 20–24, 25–29, 30–34, 35–39, 40–44, 45–49 and 50–55 years of age. Sample size calculation has been thoroughly described in the study protocol.¹⁹

Outpatients were community-dwelling patients with SSD who were approached consecutively at the outpatient units for potential participation until the recruitment target was achieved. Residential patients were recruited by means of an alphabetical list of patients with SSD present on an index-day; based on this list, residential patients were consecutively invited to participate in the study.

Participants were provided with detailed information about the study and had an opportunity to ask questions. Some of the assessment tools were completed by the treating clinician, while research assistants (RAs) helped the participants complete self-reported questionnaires if needed. Standardised clinical measures were used to collect clinical data to minimise methodological biases (see section "Measures"). The ecological monitoring was preceded by a briefing session in which the RA gave instructions about the procedures and how to effectively perform them, and was followed by a debriefing section in which the same RA collected information on study acceptability and feasibility.²⁵ During the debriefing session, outpatients and healthy controls received €25 for travel expense reimbursement.

Sociodemographic, physical and clinical assessments

For each recruited participant, sociodemographic details (see table 1 for a list) were gathered. Psychiatric history of patients was assessed using a structured ad hoc survey aimed at collecting information on the current diagnosis, illness duration and lifetime duration of psychiatric hospitalisations. The Charlson Comorbidity Index²⁷ was used for the assessment of physical comorbidities of participants. The 24-item Brief Psychiatric Rating Scale (BPRS)²⁸ was used to assess psychopathology. Negative symptoms severity was assessed with the Brief Negative Symptom Scale (BNSS).²⁹ The 43-item Specific Levels of Functioning Scale (SLOF)³⁰ was used for the assessment of levels of functioning. The WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) was used for the assessment of disability level.

Assessment of daily time use and emotions

Self-reported daily time use (i.e., daily activities) and emotions were prospectively assessed with a brief questionnaire on a smartphone-based application for EMA, developed ad hoc for the project. The mobile application included three sections: current activities, social contacts and emotions. EMA emotions were chosen from an official ‘Experience Sampling Method Item Repository’ (https://osf.io/kg376/), which provides detailed info (including psychometric information) about all items used in different EMA studies. Notifications occurred 8 times a day, from 08:00 a.m. to 12:00 p.m., for seven consecutive days. Details about the EMA study are provided in the online supplemental tables 1S and 7S.

Assessment of physical activity and data processing

PA was monitored using the wearable accelerometer-based biosensor ActiGraph GT9X Link (https://theactigraph.com/). The ActiGraph was worn on the non-dominant wrist for seven consecutive days (the same days for the EMA monitoring). See online supplemental materials for detailed information on ActiGraph’s data processing.

Statistical analyses

Data were summarised using mean and SD, median and IQR for quantitative variables, counts and percentages for qualitative ones.

Comparisons of sociodemographic and clinical variables across residential patients, outpatients and control participants were carried out through the χ² test for categorical variables and the analysis of variance test for continuous variables..

The 15 daily time use categories were first grouped into 6 categories as follows: sedentary activities (staying sick in bed, thinking, resting and doing nothing), working activities (studying/attending training courses, cleaning, cooking, tidying up the house or car, shopping, taking care of someone or something and voluntary work), leisure activities (hobbies, watching TV or listening to the radio), PA (doing sports or PA/walking), self-care (self-caring and eating/drinking/having breakfast or snack) and religious activities. Then, data on daily time use were synthesised in terms of the daily average number of times each activity was done and compared across the three groups through a Generalised Linear Mixed Model with Poisson distribution after adjusting for smoking and seasonality. Results were reported in terms of rate ratios (RRs) with their 95% CIs.

Positive and negative emotions were computed by averaging positive (happy, relaxed, quiet and full of energy) and negative (sad, tired and nervous) emotions, respectively, and synthesised in terms of the daily average of positive and negative emotions on a 0–100 scale. Similar to daily time use, emotions ratings were compared across participant groups through a Linear Mixed Model with a random intercept (patient) after adjusting for smoke and seasonality. Results were reported in terms of estimated mean differences with corresponding 95% CIs. Additional details about statistical analyses can be found in the online supplemental file. All analyses were performed with R V.4.3.0.

Sociodemographic and clinical characteristics

Table 1 shows the main sociodemographic characteristics of the three groups. Table 2 shows the clinical characteristics of the patients’ sample. When compared with outpatients, residential patients reported significantly higher illness duration (p=0.017), lifetime duration of psychiatric hospitalisation (p<0.001), BPRS score (p<0.001), BNSS score (p=0.011) and lower levels of functioning (p<0.001); they also received a significantly higher mean number of antipsychotic medications (p<0.001).

Between-group differences in self-reported daily activities

The three groups significantly differed in daily time spent in sedentary activities, working activities and self-care activities (table 3), even controlling for the number of cigarettes per day and season. Indeed, residential patients were significantly less engaged in working activities when compared with both outpatients (RR 0.41 (95% CI 0.23 to 0.73); p<0.001) and healthy controls (RR 0.25 (95% CI 0.13 to 0.46); p<0.001). In addition, healthy controls were significantly less engaged in sedentary activities when compared with both outpatients (RR 1.78 (95% CI 1.00 to 3.17); p= 0.048) and residential patients (2.50 (95% CI 1.47 to 4.23); p<0.001). Finally, residential patients spent more time in self-care activities than healthy controls (RR 1.63 (95% CI 1.09 to 2.43); p=0.0014). No differences were found between residential patients and outpatients regarding time spent in sedentary activities, working activities and self-care activities. See online supplemental table 6S for details about the differences in the 15 daily activities between the 3 groups.

Between-group differences for self-reported emotions ratings

Controlling for the number of cigarettes per day and season, we found no differences in average ratings of positive emotions between the three groups, while residential patients showed a higher negative emotions intensity when compared with both outpatients (mean difference 6.12 points (95% CI 0.13 to 12.11); p=0.04) and healthy controls (mean difference 7.38 points (95% CI 2.42 to 12.34); p=0.0015). Outpatients and healthy controls did not differ in terms of negative emotions intensity (table 3).

Between-group differences for device-measured physical activity and sedentary behaviour

The three groups significantly differed for all activity levels (both min/day and %) (figure 1 and online supplemental table 3S and figure 2S), with healthy controls showing higher PA levels than the two patient groups, even controlling for daily % of wearing time, the number of cigarettes per day and season. Time spent in different PA levels are expressed in mean min/day.

Sedentary time was significantly higher in residential patients compared with both outpatients and healthy controls (respectively RR 1.16 (95% CI 1.10 to 1.23); p<0.001); RR 1.15 (95% CI 1.15 to 1.28); p<0.001). Outpatients and healthy controls did not differ from each other for time spent sedentary (RR 1.04 (95% CI 0.99 to 1.10); p=0.10). When expressed in relative terms, the sedentary time represented 48%–51% of total wake time in patient groups, which was also a significantly larger fraction compared with healthy controls (i.e., 40%).

MVPA was significantly higher in healthy controls (91.3 mean min/day) than in both outpatients (64.1 mean min/day) and residential patients (44.6 mean min/day). Outpatients spent a significantly larger fraction of time doing MVPA per day compared with residential patients (RR 0.70 (95% CI 0.53 to 0.92); p= 0.01) and lower time when compared with healthy controls (RR 0.70 (95% CI 0.55 to 0.90); p= 0.004).

Online supplemental tables 4S and 5S show the comparison of activity levels (both min/day and %) in the three groups divided respectively by weekdays and weekends. The findings remained stable even after checking for weekdays/weekends separately, except for two results. First, we found a significant difference between outpatients and healthy controls in levels of sedentary time (RR 1.11 (95% CI 1.02 to 1.21); p=0.01) only during weekends. Second, the difference in MVPA levels found between residential patients and outpatients disappears if we look only at weekend days (RR 0.76 (95% CI 0.56 to 1.02); p=0.06).

Association between ecological indexes and clinical outcomes

Table 4 shows the results of the association between ecological indexes and clinical outcomes. MVPA was significantly associated only with the SLOF scale, with an increase of 4.95 points (95% CI 0.46 to 10.11) for 60 min/day of MVPA. The amount of self-reported time spent in leisure activities was significantly associated with an increase in the BPRS score (2.07, 95% CI 0.65 to 3.33) and a reduction in SLOF score (−4.01, 95% CI −6.31 to −0.80). No relationships were found between clinical outcomes and intensity of emotions.

Daily time use

Compared with healthy individuals, patients (especially if living in RFs) were generally engaged for more time in sedentary activities and self-care activities and for a lesser time in working activities. Moreover, time spent in leisure activities was associated with higher psychiatric severity and lower levels of functioning. These results are in line with previous EMA studies which found higher self-reported inactivity time in patients with SSD when compared with healthy controls^{5 6} and found an association between specific activities (i.e., work activities) and clinical outcomes (ie, hallucinations, self-rated health, mastery and quality of life).^{31 32}

The marked differences in daily time use between patients with SSD and healthy controls are likely to be at least partly due to the severity and nature of psychiatric symptoms, particularly negative symptoms (eg, those that affect motivation, concentration, organisational and interpersonal skills). Negative symptoms are extremely difficult to treat and they can profoundly compromise the daily functioning of patients with SSD,³³ possibly leading to a large amount of time spent doing nothing. These differences may be also due to the higher proportion of patients not working/studying and with a single status, which may be in turn associated with a psychiatric history, lower psychosocial functioning and fewer relationships. In addition, residential patients showed more severe symptomatology and could also be more restricted on where and the types of activities they did, limiting the opportunity to do different activity types.

Daily emotions

Patients with SSD living in RFs reported higher intensity of negative emotions if compared with healthy controls; on the contrary, there were no differences in subjectively reported negative emotions between outpatients and healthy controls. The higher degree of negative emotions among residential patients was unrelated to their psychiatric symptoms or levels of functioning. This result is partially in line with a meta-analysis of 12 EMA studies,³⁴ showing that people with SSD consistently report both more negative and less positive emotions than healthy controls; however, in these studies treatment setting was rarely assessed, and was not one of the main variables to be considered. Characteristics of the living environments should be carefully considered whenever the quality of daily emotions is assessed.

Physical activity

Patient groups and healthy controls in this study appear to reach the minimum level of PA required to maintain health, that is, 23 min/day of MVPA.³⁵ However, when compared with healthy controls, patients with SSD spent more time in sedentary behaviour—as assessed by the accelerometer—and their PA levels were associated with levels of functioning, especially if living in RF.

Our results about residential patients are in line with findings of previous studies, which found that patients with SSD spend on average about 45 min/day engaged in MVPA,¹ or about 5% of the daytime.³⁶ However, in our study outpatients spent more time engaged in MVPA (i.e., about 64 min/day, 8.5%). This difference enforces the need to do independent analyses based on treatment setting when looking at PA levels of individuals with SSD. Moreover, our findings support studies that found that individuals with SSD have lower PA levels compared with healthy controls and that these levels are associated with clinically relevant psychiatric outcomes (eg, severity of positive symptoms, illness chronicity, higher antipsychotic dose, depression and poorer quality of life).^{1 12}

The differences in PA levels that we found between patients with SSD and healthy controls may be due to the association with a variety of clinical factors (eg, severe negative symptoms, medication side effects, cognitive and sensory impairments, lack of motivation and energy, cognitive overload, poor education as well as living conditions and environmental factors (eg, stigma and discrimination, lack of supportive social network, limited access to safe spaces, financial constraints, transportation barriers, lack of individualised programmes).³⁷ Addressing these environmental factors and providing targeted support, such as creating safe spaces, offering transportation assistance, providing financial support and designing inclusive and individualised exercise programmes, can help promote PA among individuals with SSD.

Limitations and strengths

The study was conducted during the COVID-19 pandemic, and this may have affected both the PA monitoring and the evaluation of daily time use and emotions. However, since the recruitment of patients and controls took place at the same time, this change is likely to have affected both study groups. Moreover, SSD diagnoses were based only on medical records because of financial and logistic limitations. The measurement of activity at the wrist usually overestimates PA and can hardly distinguish between sitting and standing. This may raise problems in defining sedentary behaviour, since all PA ≤1.5 MET was counted as sedentary behaviour without considering body position.

However, this is the first study that assessed PA, daily activities and emotions in patients with SSD in different treatment settings and compared them with healthy controls. This study was performed with a multimethod approach that integrated both self-reported and objective, longitudinal measures for the assessment of targeted ecological indexes. Finally, the involvement of 10 recruitment centres makes our findings and the generalisability of the conclusions stronger.

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study was approved by the Ethical Committees (ECs) of the three main participating centres (IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 31 July 2019; no. 211/2019; Area Vasta Emilia Nord, 25 September 2019; no. 0025975/19 and ASST of Pavia, 2 September 2019, no. 20190075685) and by the ECs of all participating sites. Participants gave informed consent to participate in the study before taking part.