A complementary approach in the treatment of schizophrenia: physical activity and exercise

Authors

Abstract

Aim This review aims to synthesize current evidence regarding the psychiatric, neurobiological, and physical health effects of physical activity and structured exercise interventions in individuals with schizophrenia.
Methods A narrative review of randomized controlled trials, meta-analyses, and systematic reviews evaluating aerobic, resistance, and mind–body exercise interventions in schizophrenia spectrum disorders was conducted.
Results Exercise demonstrates beneficial effects, particularly on negative symptoms and cognitive functioning. Proposed mechanisms include dopaminergic modulation, enhanced neuroplasticity, increased brain-derived neurotrophic factor (BDNF) levels, and hippocampal adaptations. In addition, structured exercise improves cardiorespiratory fitness and contributes to reductions in cardiometabolic risk factors.
Conclusion Exercise represents a safe, evidence-based complementary intervention in schizophrenia treatment. Its integration into routine care may improve symptom burden and quality of life. However, further high-quality, methodologically rigorous randomized controlled trials are needed to strengthen the level of evidence.

Keywords

Introduction

Schizophrenia is a chronic and severe psychotic disorder characterized by disturbances in emotional, cognitive, and perceptual processes; it profoundly affects an individual’s relationship with reality and leads to marked impairments in daily functioning.¹ The disorder encompasses positive symptoms, negative symptoms, and cognitive deficits.² It typically emerges during late adolescence or early adulthood and affects approximately 0.25–0.75% of the global population.³
Schizophrenia has profound effects not only on psychiatric symptoms but also on overall health and lifestyle behaviors; as a result, individuals with schizophrenia exhibit significantly higher rates of morbidity and mortality compared with the general population.⁴ The risk of all-cause mortality among individuals diagnosed with schizophrenia is increased by approximately 2.5–3 times, and life expectancy is reported to be 20–30 years shorter in most studies.⁵ These premature deaths are attributed not only to psychiatric causes such as suicide but predominantly to cardiovascular, metabolic, and respiratory diseases.⁶
Moreover, schizophrenia substantially impairs individuals’ ability to maintain healthy daily routines and lifestyle behaviors. Disturbances in the sleep–wake cycle and poor sleep quality are commonly reported among patients.⁷ In addition, irregular dietary patterns, increased consumption of high-calorie and low-nutrient foods, and higher rates of weight gain and obesity have been widely documented.⁸ In parallel, negative symptoms—particularly reduced motivation and social withdrawal—are closely associated with physical inactivity and sedentary behavior, further exacerbating cardiometabolic risk. Furthermore, social isolation, limited social participation, and reduced functional capacity adversely affect both mental well-being and overall health outcomes.⁴
Cognitive impairments inherent to the disorder further exacerbate this clinical burden. Deficits in attention, memory, executive functioning, processing speed, and planning abilities interfere with the performance of daily living activities, reduce treatment adherence, and hinder the adoption of healthy lifestyle behaviors, thereby diminishing functional independence.⁹
In addition, comorbid medical conditions, lifestyle-related risk factors, barriers to accessing health care, and poor treatment adherence contribute substantially to the elevated morbidity and mortality observed in individuals with schizophrenia. Conditions such as diabetes, hyperlipidemia, obesity, and tobacco use are more prevalent in this population and exert detrimental effects on overall health.^10,11 Taken together, this multidimensional biopsychosocial burden suggests that lifestyle-based interventions—particularly physical activity—may serve as an important adjunct to pharmacological treatment in the comprehensive management of schizophrenia.
Physical Health Problems in SchizophreniaPhysical health comorbidities accompanying the clinical presentation of schizophrenia further amplify the overall burden of the disorder.¹² Although the reduction in life expectancy observed in schizophrenia has often been attributed to psychiatric causes such as suicide, a substantial proportion of excess mortality is, in fact, driven by cardiovascular disease and other physical health conditions.¹³ The heightened cardiovascular disease burden in individuals with schizophrenia has been linked to a greater prevalence of lifestyle-related risk factors, including unemployment, tobacco use, and harmful alcohol consumption. In addition, cardiometabolic risk factors such as obesity and insufficient physical activity have been reported to occur more frequently in this population, further compounding adverse health outcomes.¹⁴ The prevalence of metabolic syndrome in individuals with schizophrenia is reported to be two to three times higher than that observed in the general population, indicating a high-risk clinical profile characterized by the co-occurrence of abdominal obesity, dyslipidemia, hypertension, and type 2 diabetes mellitus.^15,16 Moreover, certain antipsychotic medications—particularly clozapine and olanzapine—have been associated with an increased cardiovascular risk through adverse effects such as appetite stimulation, weight gain, and impaired glucose metabolism.¹⁷ In addition to pharmacological factors, growing evidence highlights substantial disparities in access to physical health care and the likelihood of receiving adequate medical treatment among individuals with psychotic disorders, which further complicates the effective management of physical comorbidities.¹⁰
Antipsychotic Treatments and Metabolic Side EffectsMetabolic syndrome is frequently observed in individuals with schizophrenia, even in antipsychotic-naive cases, and its clinical expression often becomes more pronounced shortly after the initiation of antipsychotic treatment.¹⁸ The progressive increase in the prevalence of metabolic syndrome with longer treatment duration suggests that these adverse effects may exhibit a cumulative pattern over time.¹⁹ Furthermore, the development of diabetes mellitus soon after the commencement of antipsychotic therapy, along with the rapid improvement of metabolic abnormalities following treatment discontinuation, supports the notion that these effects may be mediated by direct and fast-acting pharmacological mechanisms.²⁰ Importantly, the occurrence of similar metabolic disturbances during the use of antipsychotic medications for non-schizophrenia indications further indicates that these metabolic effects are more likely attributable to antipsychotic agents themselves rather than being intrinsic to the underlying psychiatric disorder.²¹

Materials and Methods

The study was designed as a narrative literature review aimed at synthesizing current evidence regarding the psychiatric, neurobiological, and physical health effects of physical activity and exercise in individuals with schizophrenia.
Relevant publications were identified through a comprehensive database search of Scopus, Web of Science, PubMed/MEDLINE, EBSCO, and Google Scholar databases. Studies published between January 2001 and December 2025 were considered. Searches were conducted using the following keywords individually and in combination: “schizophrenia,” “physical activity,” “exercise,” “aerobic exercise,” “resistance training,” “mind–body exercise,” “rehabilitation,” “cardiometabolic risk,” and “metabolic syndrome”.
Randomized controlled trials, systematic reviews, and meta-analyses evaluating exercise-based interventions in individuals diagnosed with schizophrenia or schizophrenia spectrum disorders were eligible for inclusion. Studies conducted exclusively with healthy populations, investigations focusing on non-exercise lifestyle interventions, and publications lacking sufficient methodological detail were excluded. Duplicate records were also removed during the screening process.
The exercise modalities considered in the review included aerobic training, resistance training, mind–body exercise (MBE) (e.g., yoga and tai chi), and multicomponent lifestyle programs. The primary outcomes of interest comprised psychiatric symptom severity (positive, negative, depressive, and cognitive symptoms), neurobiological indicators (such as brain-derived neurotrophic factor levels and hippocampal changes), cardiorespiratory fitness measures (e.g., maximal oxygen consumption [VO₂max]), metabolic parameters, and quality-of-life outcomes.
In addition to database searches, the reference lists of eligible studies were manually screened to identify further relevant publications. Only English-language articles were included. The findings obtained from the selected studies were synthesized and presented thematically under the headings of psychiatric, neurobiological, and physical health effects of exercise. The methodological strengths and limitations of the included studies were critically evaluated during the synthesis process.
Ethical Approval
This study did not require ethical approval according to the relevant guidelines.
Reporting GuidelinesThis narrative review was prepared in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations.

Results

Physical Activity Levels in SchizophreniaNegative symptoms, diminished motivation, cognitive impairments, and reduced functional capacity are among the principal clinical factors contributing to low levels of physical activity and increased sedentary behavior.^22,23 In addition, stigma, impaired social functioning, and poorer quality of life further hinder patients’ ability to maintain an active lifestyle.²⁴ Moreover, evidence indicating that sedentary behavior independently elevates the risk of cardiovascular disease, type 2 diabetes, and related mortality—regardless of overall physical activity levels—suggests that inactivity itself constitutes a distinct and clinically significant risk factor in individuals with schizophrenia.²⁵
Pathophysiology of Schizophrenia and the Neurobiological Effects of ExerciseAlthough pharmacological and psychotherapy-based interventions have traditionally been the mainstay of schizophrenia treatment, growing scientific evidence indicates that physical activity and exercise should also be considered essential components in both the prevention and management of the disorder.²⁶
Understanding the therapeutic effects of exercise first requires an appreciation of the neurophysiological mechanisms underlying schizophrenia. Core pathological processes—including dopaminergic dysregulation, impaired neuroplasticity, and structural brain atrophy—represent primary targets for exercise-based interventions. The dopamine hypothesis of schizophrenia describes dysfunction across four major dopaminergic pathways originating from the ventral tegmental area. Hyperdopaminergic activity within the mesolimbic pathway is primarily associated with positive symptoms, whereas reduced dopamine transmission or hypofunction in the mesocortical pathway projecting to the prefrontal cortex is closely linked to negative symptoms and cognitive deficits.^27,28
Physical activity appears to exert a regulatory or balancing effect on these systems. Evidence suggests that regular aerobic exercise can modulate dopamine release and receptor sensitivity in striatal regions.²⁹ In particular, dopamine D2 receptor activity within the nigrostriatal pathway has been identified as a central mechanism governing the balance between cortical excitation and inhibition induced by exercise, thereby facilitating motor function and skill acquisition.³⁰ At the prefrontal level, insufficient stimulation of dopamine D1 receptors has been associated with increased neural “noise” and inefficient cognitive processing. Exercise is thought to enhance D1 receptor functionality, contributing to improvements in working memory and executive functions.^31,32
Another key neuropathological feature of schizophrenia is impaired neuroplasticity, defined as the brain’s reduced capacity to adapt and reorganize. Patients commonly exhibit structural abnormalities, including hippocampal volume reduction and neuronal atrophy, particularly in regions critical for learning and memory. One of the most prominent biochemical correlates of this process is a significant decrease in serum levels of brain-derived neurotrophic factor (BDNF).
Exercise is recognized as one of the most potent non-pharmacological strategies for increasing BDNF expression in the brain. Molecules released from skeletal muscles during aerobic activity can cross the blood–brain barrier, stimulate hippocampal neurogenesis, and enhance synaptic plasticity.^33,34,35 Moderate- to high-intensity exercise has been associated with increases in hippocampal volume, and these structural changes correlate with improvements in working memory performance.^36,37,38 Elevated BDNF levels not only support structural preservation but may also enhance the effectiveness of cognitive rehabilitation by promoting a state of “neuroplastic readiness”.^32,39 However, while aerobic exercise has been shown to increase hippocampal blood volume in healthy individuals, findings in patients with schizophrenia remain inconsistent.^40,41 Overall, accumulating evidence indicates that exercise exerts beneficial effects in the treatment of schizophrenia and related psychotic disorders, contributing to reductions in both positive and negative symptoms as well as improvements in quality of life.³⁶
Physical Health Effects of Exercise in SchizophreniaCardiorespiratory fitness is a strong and independent predictor of cardiovascular disease and all-cause mortality.⁴² Exercise interventions implemented in individuals with schizophrenia have demonstrated meaningful improvements in this domain. Specifically, 6–8-week structured exercise programs have been associated with increases of approximately 4–4.5 ml/kg/min in maximal oxygen consumption (VO₂max), a key indicator of cardiorespiratory capacity.⁴¹ A 2015 meta-analysis further confirmed that exercise significantly enhances cardiorespiratory fitness, with exercise groups showing superior performance compared with control conditions.⁴³ Longer-term aerobic programs lasting 12–24 weeks have also been shown to produce significant increases in VO₂max.^37,44,45 Moreover, patients with lower baseline cardiorespiratory fitness—particularly women—appear to derive greater metabolic benefits from exercise, including reductions in triglyceride levels.⁴⁴
Exercise also exerts notable effects on metabolic parameters. Some studies report that 150–300 minutes per week of moderate-intensity physical activity can result in clinically meaningful weight loss.⁴⁶ However, comprehensive meta-analyses indicate that, in the absence of concomitant dietary modification, exercise alone produces only modest changes in body mass index (BMI) or waist circumference.^37,47 Importantly, improvements in cardiorespiratory fitness occur independently of weight loss and are themselves associated with reduced mortality risk.^44,48
In recent years, high-intensity interval training (HIIT) protocols have emerged as an effective alternative approach. An 8-week HIIT program has been reported to yield significant improvements in body weight, BMI, resting heart rate, and blood pressure.⁴⁹ Similarly, Heggelund et al. documented improvements in physiological parameters and an approximately 12% increase in VO₂max following an 8-week HIIT intervention.⁵⁰ Additionally, combined strategies that integrate physical activity with motivational interviewing have been shown to facilitate weight reduction in obese patients over a 12-week period. Multicomponent lifestyle interventions incorporating psychosocial treatment, behavioral therapy, and aerobic exercise have also demonstrated reductions in waist circumference, BMI, and body weight, although without significant changes in blood lipid or glucose levels.⁴⁸
Effects of Exercise on Psychiatric Symptoms in SchizophreniaAntipsychotic medications, which constitute the first-line treatment for schizophrenia, are generally effective in reducing positive symptoms; however, they show limited or minimal efficacy for negative and cognitive symptoms.⁵¹ Consequently, the need for adjunctive non-pharmacological interventions has become increasingly evident. Physical activity and exercise have emerged as safe, cost-effective strategies with beneficial effects on both psychological and physical health outcomes.^51,52 A growing number of randomized controlled trials and meta-analyses indicate that exercise can improve various psychological parameters in individuals with schizophrenia. Nevertheless, some studies have been criticized for methodological limitations and heterogeneity, underscoring the need for further high-quality evidence.^53,54
A comprehensive meta-analysis conducted in 2016 evaluated 29 studies involving a total of 1109 participants and demonstrated that aerobic exercise and yoga were associated with improvements in positive, negative, and general symptom severity, as well as quality of life, overall functioning, and depressive symptoms. Notably, yoga was found to contribute to improvements in long-term memory, a key cognitive domain. Overall, physical exercise was identified as a robust adjunctive intervention for enhancing clinical symptoms, functional outcomes, and psychological well-being in patients with schizophrenia.⁵²
In a 2019 systematic review and meta-analysis, Vogel et al. examined the effects of MBE and aerobic exercise on negative symptoms.⁵⁴ Across 22 randomized controlled trials (n = 1249), physical exercise demonstrated a significant overall beneficial effect on negative symptoms. Subgroup analyses revealed moderate effects for MBE interventions and smaller, yet still favorable, effects for aerobic exercise.
More recently, a 2024 study synthesizing findings from systematic reviews and meta-analyses reported that tai chi, yoga, and aerobic exercise were effective in reducing negative symptoms, with aerobic exercise showing comparatively greater benefits than yoga. Both aerobic exercise and yoga were also associated with reductions in depressive symptoms and improvements in quality of life.⁵⁵
In a 2025 meta-analysis by Wang et al., 32 randomized controlled trials (n = 1773), with intervention durations ranging from 4 to 24 weeks and including aerobic, resistance, MBE, combined exercise, and yoga protocols, were analyzed.⁵³ All exercise modalities were found to improve negative symptoms. The magnitude of effect was ranked as follows: yoga, resistance training, aerobic exercise, combined exercise, and MBE. The authors further emphasized that individual characteristics, including age and geographical context, should be considered when designing personalized exercise interventions.

Discussion

Physical inactivity and sedentary behavior are highly prevalent among individuals with schizophrenia, largely as a consequence of the disorder’s natural course and treatment-related adverse effects.⁵⁶ Compared with healthy controls, patients demonstrate an average daily deficit of approximately 37.5 minutes of moderate-to-vigorous physical activity.³⁵ Importantly, exercise interventions in schizophrenia spectrum disorders have been shown to produce evidence-based improvements in domains where pharmacological treatments often remain insufficient, including negative symptoms, cognitive functioning, and physical health risks such as metabolic syndrome.^51,52,53
To systematically implement exercise as a therapeutic strategy, the frequency, intensity, time, and type (FITT) framework—comprising frequency, intensity, time, and type—has been recommended as a standard guide for exercise prescription.⁵⁷ Guidelines from the European Psychiatric Association advise at least 2–3 exercise sessions per week, with greater symptomatic benefits observed in programs conducted 3–5 days per week.^57,58 To maximize both physical and mental health outcomes, exercise is generally recommended at moderate-to-vigorous intensity, and the “talk test” is frequently used in clinical settings as a practical method for monitoring intensity.^58,59 Sessions are typically planned to last 30–60 minutes, targeting a weekly total of 90–150 minutes of moderate-to-high intensity activity; some evidence suggests that 100–220 minutes per week may be optimal for reducing negative symptoms. For sustained clinical benefits, interventions are recommended to continue for at least 8–12 weeks.^57,60
Regarding exercise modality, aerobic training currently has the strongest evidence base. However, resistance exercises and mind–body exercise (MBE) approaches such as yoga and tai chi—implemented either alone or in combination within multicomponent (“combined”) programs—may provide broader benefits across both physical and psychological health outcomes. Accordingly, exercise prescriptions should be individualized according to each patient’s physical capacity, clinical status, and motivational level.^57,58 Detailed information on the types of exercises applied and their effectiveness reported in the literature is provided in Supplementary Table 1.

Limitations

This review has several limitations. First, as a narrative review, it does not follow a systematic search strategy; therefore, selection bias cannot be entirely excluded. Second, the included studies demonstrate considerable heterogeneity in terms of exercise type, intensity, duration, sample size, and outcome measures, which limits direct comparability. Third, many studies have relatively small sample sizes and short follow-up periods, reducing the strength and generalizability of the findings. Additionally, variability in antipsychotic treatment, illness duration, and baseline physical fitness may have influenced reported outcomes.

Conclusion

Schizophrenia is a multidimensional disorder that extends beyond positive symptoms and is characterized by prominent negative symptoms, cognitive impairments, and substantial physical health problems, all of which contribute to a markedly reduced life expectancy. The excess mortality and morbidity observed in this population are largely attributable to cardiovascular and metabolic diseases, highlighting the critical role of sedentary behavior, low levels of physical activity, and the metabolic adverse effects associated with antipsychotic treatments. Accordingly, effective management of schizophrenia should not be limited to pharmacological strategies alone but should incorporate comprehensive and holistic approaches.
The evidence summarized in this review indicates that physical activity and exercise represent complementary, evidence-based interventions in the treatment of schizophrenia. Exercise exerts beneficial effects, particularly on negative symptoms, cognitive functioning, and overall functioning, through mechanisms such as dopaminergic modulation, enhanced neuroplasticity, and increased BDNF levels. In addition, by improving cardiorespiratory fitness and reducing metabolic risk factors, exercise contributes to better physical health outcomes and may ultimately help lower long-term mortality risk.
In conclusion, the structured and individualized integration of exercise into schizophrenia treatment plans is of critical importance for reducing symptom burden, addressing physical health disparities, and enhancing quality of life. The systematic “prescription” of exercise in clinical practice should be considered a key component of a more holistic and sustainable treatment model for schizophrenia.
Future research should focus on well-designed randomized controlled trials with adequate sample sizes to determine the optimal type, intensity, duration, and frequency of exercise interventions in this population. High-quality studies with robust methodological designs are particularly needed to strengthen the existing evidence base.

Declarations

Abbreviations

BDNF: brain-derived neurotrophic factor
BMI: body mass index
FITT: frequency, intensity, time, and type
HIIT: high-intensity interval training
MBE: mind–body exercise
VO₂max: maximal oxygen consumption

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About This Article

Received:

February 7, 2026

Accepted:

April 8, 2026

Published Online:

May 4, 2026