Hello and welcome. I'm Dr. John Torres, the Director of Digital Psychiatry at Beth Israel Deaconess Medical Center and technology expert for SMI Advisor. I'm pleased that you're joining us today for our SMI Advisor webinar titled Aerobic Exercise and Neurocognition in Serious Mental Illness, Efficacy in Clinical Applications via Novel Technologies. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts across the SMI clinician community, our interdisciplinary effort has been designed to help you get answers to care for your patients. And now it's my great honor to introduce our faculty for today's webinar, Dr. David Kimhi. Dr. David Kimhi is an Associate Professor and the Director of Experimental Psychopathology Laboratory and a Program Leader for the New Interventions in Schizophrenia at the Department of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York, New York. Additionally, Dr. Kimhi serves as a Research Scientist at the Mental Illness Research, Education, and Clinical Center, MIRAC, at the James J. Peters VA Medical Center in the Bronx, New York. Dr. Kimhi completed three-year NIMH-funded Postdoctoral Fellowship in Schizophrenia Research at the Department of Psychiatry at Columbia University. During this time, he also served as a Beck Institute Scholar at the Beck Institute for Cognitive Behavioral Therapy. Following his postdoctoral training, he joined the Department of Psychiatry at Columbia University in the New York State Psychiatric Institute, where he served as faculty for 10 years before joining Mount Sinai in the Mental Illness Research, Education, and Clinical Research Center. So, Dr. Kimhi, thank you so much for joining today's webinar and sharing your expertise on this important topic. I'm going to let you take it away. Thank you very much, Dr. Torres, for the kind introduction. I'll start with just the common disclosures. I have no financial relationship with commercial interest or any conflict of interest to report. And for this talk today, I hope people will, at the end of it, will, we achieve a few objectives. One is that participants would be able to describe the impact of neurocognitive deficits on daily functioning in people with a serious mental illness, be able to discuss the currently available treatments for neurocognition in this population, be able to identify five key benefits of aerobic exercise for this population, and also be able to describe how novel digital technologies can be leveraged to enhance physical activities in people with serious mental illness. Now, when we talked about the cognitive functioning in people with schizophrenia, for example, and this is also true for many other serious mental illness, people with schizophrenia display a broad range of neurocognitive difficulties, um, these are a number of, across a number of domains, such as working memory, processing speed, etc. And these difficulties have been identified as major determinants for poor functioning and disability. And while we are all familiar with the psychotic or the positive symptoms of schizophrenia, which are kind of like the hallmark of the disorder, it is more the, actually the cognitive difficulties that are better predictors of daily functioning and make a difference in terms of people's life, their ability to function, basically hold a job, go to school, have relationship, etc. And we have at this point many, many studies that document that these deficits are common and are widespread. I mean, this is an example on the right here, results from a study by August and colleagues. So you'll see here the individuals with schizophrenia are the white bars, the healthy controls are the dark bars. And generally, people with schizophrenia score on cognitive tests like this. This is the matrix cognitive, consensus cognitive battery. So they score about between one to two and a half standard deviation below the mean of healthy individuals. Now, obviously, this is, you know, given the potential impact of cognitive deficits on functioning, this has been a major target for development of treatments. So in terms of pharmacotherapy, first and second generation antipsychotic medications, which are not designed, were not designed to target cognition, not surprisingly, they're not, they have a limited efficacy in terms of improving those abilities. A few, about a decade ago, NIMH had an initiative to try to develop or provide an infrastructure for pharmaceutical companies to test and examine their pharmacological agents that have been in the pipeline to try to see if any of them show any promise. And unfortunately, the results have been rather disappointing. In other words, no magic pill for neurocognition. Another type of intervention that has been used extensively to try to improve neurocognition is cognitive remediation. And studies using cognitive remediation have shown much more promising results. Although, again, the benefits have been modest, and there's a quite large variability in terms of treatment responses. There have been some studies that shown quite strong responses. However, some others have not, and it's not fully clear why, sort of what's the active ingredient. For example, there was a recent large randomized clinical trial, 150 patients, quite intensive cognitive remediation protocol, and over six months, and they reported no cognitive benefits. So there's quite a bit of effort right now to try to kind of identify these core components of treatment and standardize them, but this is still kind of an ongoing effort at this point. So looking at the sort of the common treatments that have been used to target poor neurocognition and schizophrenia and other serious mental health conditions, it seems that there's a remain an urgent need to identify a novel approaches for development of treatments that target neurocognitive difficulties in people with schizophrenia and SMI. Now, when we talk about the neurobiology of neurocognition, so enhanced neurocognitive functioning is related to the brain's ability to modify neural connectivity and function. This neuroplasticity is dependent on the support of neurotrophins, which is a group of proteins, a family of proteins that are very common in the brain, and basically their job is to signal, among many other things, to signal neurons to survive differentiating group. And among this family of proteins, the brain-derived neurotrophic factor has been particularly abundant and also has a wide repertoire of neurotrophic and neuroprotective properties. Now, what we know from studies is that BDNF is actually found to be lower in people with schizophrenia compared to healthy controls. This is including among drug-naive patients. BDNF levels are not significantly impacted by age, duration of illness, or degree of psychopathology. There are also depletions of BDNF. This seems to be identified in multiple brain regions, so this is not localized to any particular region. And there are some studies that show that BDNF has been linked to poor short-term memory and smaller hippocampal volumes. However, given that the central role or central ability of BDNF to contribute to play a central role in neurocognition, it looks like a promising target in terms of trying to upregulate BDNF as a way to improve cognitive functioning in people with schizophrenia. Now, one activity that is known to upregulate neurotrophins in general, and BDNF in particular, is aerobic exercise. In fact, among all the neurotrophins, BDNF has been found to be the most susceptible to upregulation by aerobic exercise. And this upregulation goes in a dose-response manner. In other words, the more intense the exercise, the higher the activity-related secretion and synthesis of BDNF. And this is kind of consistent with what we know from many, many animal studies that strongly support the positive influence of aerobic exercise on neurocognition. That's, you know, it increases self-proliferation and survival. There's a lot of good things in the brain, multiple regions. So it's exercises strongly supported by animal literature. Among people, and I believe that photo is Photoshop. I hope it's Photoshop for the sake of the guy. But in humans, there's a similar extensive literature that support the positive impact of aerobic exercise. And this is in adolescents, young adults, older adults. Pretty much, this is across the lifespan. There's been a number of meta-analysis studies looking at various domains of cognitive functioning. And generally, the results are very positive. So it seems to be kind of converging animal and human research literatures that support the positive influence of aerobic exercise on neurocognition across the mammalian lifespan. Now, another piece of evidence that sort of links to this nicely is that what we know is for many people with schizophrenia, and for that matter, for many people with SMI, many of them have a very sedentary lifestyle. For example, some studies found that 98% of schizophrenia patients, some studies found low aerobic fitness. Between 25% to 30% of individuals report no physical activity. And many others demonstrate very low energy expenditure during kind of daily functioning as well as part of testing. In one of our early studies, we looked at aerobic fitness as indexed by VO2max in people with schizophrenia and healthy controls. So you have the distribution here on the right. And just kind of to give people a reference, so VO2max, essentially, it's an index of how people use oxygen as part of physical activity, to put it in a very simple way. And generally, so the index here is going from 20 to up to about to 35. Most healthy individuals will score typically at the upper 20s, lower 30s. If you're physically active, you'll probably score in the upper 30s. If you're really, you know, practicing for a marathon, you probably have 40s to 50s, and professional athletes will have 60 and above. So as you can see here, among the people with schizophrenia, only 6% of the sample scored above 30. The vast majority of them had very, very low aerobic fitness. Some people had as low as a score of 12, which someone with a score of 12 will have difficulties going up a flight of steps. So there are substantial differences in terms of aerobic fitness between people with schizophrenia and SMI and healthy individuals. And this is important because we find that that ability, the aerobic fitness, is highly correlated both with cognitive functioning, this was measured by the Matrix Consensus Cognitive Battery, MCCB, and as well as your daily functioning. And daily functioning here is by informant, so this is not the patient. This is reports by somebody that knows them, that we ask them how they're functioning in various domains, and these two were like highly correlated. So this kind of really got piqued our interest, and we decided to develop a study to actually see if we can improve aerobic fitness, can we improve cognitive and daily functioning. So this is a study that we did a few years back. This was funded by a generous grant from NIMH, and it was basically a small, single-blind, randomized clinical trial comparing aerobic fitness versus treatment as usual. So participants in both groups continued to receive their regular psychiatric and medical care. Just one group also received aerobic fitness, and we focused on three target variables, neurocognition, aerobic fitness, and also looking at BDNF as a potential mechanism. In terms of trying to assess our intervention, so we had a very modest gym in our institution, a couple of treadmills, stationary bike, and elliptical machine, something that you'll find pretty much every self-respecting gym. However, we were concerned about whether exercising on this equipment will become boring, and as many of you may know, running on a treadmill can get old very quickly, and so we're thinking about how can we make it more interesting and more sexy, more fun, and our approach to do that is using novel technologies. In this case, active play video game consoles. The one we use is Xbox Kinect, and essentially, the system, the way it works is it's essentially gamifying the exercise. What it does, the Kinect is a camera that take a video clip, essentially live video clip, of the participant that stands in front of it, in front of the TV, and create an image of them and place it on the TV. It's an avatar, and as the person is moving, the avatar is moving simultaneously, so if the person is jumping, the avatar is jumping. If the person is raising their hands, the avatar is raising their hands, etc. So essentially, it allows the person to interact with objects in the virtual environment live, and maybe it's sort of like the best way to kind of get a sense of this. If people are not familiar with the system, we have a bit of a short clip of what this might look like. So this is one of the games that we used. It's called Wall Breaker, and the target here is essentially a person have to punch boxes, ice boxes, to break them. This is the game loading. So this is the avatar, and the person, this is what the person will see on the screen, and as they move, the avatar will move simultaneously. This is individualized, so there's various levels here, some initial levels, so very low intensity, and as you get more advanced, you have more advanced targets. The voice in the background kind of cheerlead you. This is individualized, so you log in, you get scores for that. This is interval training. Typically, each section is about between three to five minutes. It's a commercial package. It's off the shelf. You can buy it. At the time, it was about 50 bucks per system for, I guess, have about 25 games or so, about half of them aerobic in nature, similar to this. I imagine today it's probably much cheaper. So essentially, people essentially play the games and in the process actually exercise, and you can get your heart rate running quite a bit from this. So that's the intervention. In terms of aerobic fitness, we use the VO2max. This is a fairly standard protocol. It's considered the gold standard, biological standard, to measure aerobic fitness. Now, other concern, other than trying to make the intervention interesting, is we're concerned about intervention fidelity. And one of the challenges of exercise studies is very few exercise studies report data on intervention fidelity. And this is critical because it makes it difficult to compare between studies with divergent results. And typically, when the studies do report it, it tends to be more of the number of session or percentage of session a participant attended. And generally, this is not a very good index because, as I'm sure all of you know, going to the gym is not the same thing as exercising. And a lot of times people can go to the gym, but they exercise very minimally. So our goal was to try to also, in addition to attendance, capture people's experience while exercising sort of the in-session engagement. And our way to do that is, again, is using kind of off-the-shelf technology. Use this commercially available chest straps and watches. You can buy, again, at the time, it was about $400. Again, I imagine today's probably cheaper. And for each individual that came to the study and started, we used the baseline VO2max to determine the aerobic fitness and have an individualized exercise plan, which consisted 60% of maximal heart rate on week one, 65 on week two, 70 on week three, and 75 on week four to 12. So for example, if an individual had a 200 maximal heart rate at the beginning of the study, so their target during the first week would be, the target heart rate would be 120 plus minus five. And we programmed the watches to beep if the heart rate goes above or below this level and instructed the trainer to kind of encourage people to stay within their window. So, but what it allows us is, that data was recorded and downloaded at the end of the study. So we can actually see what proportion of the study or the exercise participants spent at their designated intervention. So it's a very high fidelity process. And so results of this pilot study, we published a few years back, this is in Schizophrenia Bulletin in 2015. And in terms of the aerobic fidelity, so we could see that based on our data, participants spent 25% of their session with heart rate between 60 to 69% of the maximal heart rate, 27% of the session time between 70 and 79 and so on. And they spent only 11% of all the sessions times, across the 12 weeks of the intervention, three times a week, only 11% under the 60% target. So it was a very, very good intervention fidelity. In other words, people not only showed up, but actually exercised. In terms of looking at some results, so this figure displayed the association between changes in aerobic fitness, which you see at the bottom and changes in neurocognitive functioning. The aerobic exercise group are in the blue diamonds, the treatment as usual are in the white. There's a quite strong correlation between it to 0.54. Going improvement in aerobic fitness was strongly associated with improvement in neurocognitive function. Now, if you look at the head-to-head comparison, what you have here, the aerobic exercise group in dark blue, I'm sorry, the aerobic fitness in dark blue, the neurocognitive functioning in light blue. And then looking at the aerobic exercise group versus treatment as usual, so the aerobic, not surprisingly, the aerobic exercise group increased their VO2 max by nearly four points versus virtually no change in the treatment as usual one. And most importantly, the aerobic exercise group increased their neurocognitive functioning by four T-scores versus a small decline in the treatment as usual. Now, these differences were significant. And actually, just to kind of get a reference of this, so if you recall at the beginning, the first slide I stated that people with schizophrenia score one between one to two and a half standard deviations below the mean compared to healthy controls. So our 12-week intervention here, the improvement in four T-scores basically represent improvement equivalent to 16 to 40% of the reported deficits using those one to two and a half standard deviations. And specifically in terms of our particular sample, it was a 24% improvement in our sample. So one way to think about it is our 12-week intervention reduced the deficits that people with schizophrenia experienced in terms of neurocognition by a quarter, which is quite a bit. Now, in terms of looking at mechanism, we were interested in BDNF. So again, hierarchical stepwise regression analysis indicated that after controlling to a host of other variables, increases in BDNF predicted about 15% of the neurocognitive functioning improvement or variance in people with schizophrenia. And again, I mean, considering how many hundreds of proteins are in the brain, just one of them accounting for such a large amount of variance, that's actually quite impressive. It was much, much bigger than we anticipated. Now, so our study came about 2015. Since then, there have been a few other studies. There's quite a bit of a literature now. And generally, the results are consistent with our studies. This is a meta-analysis conducted by Joe Firt and colleagues and they find, if you look at the figure on the right, you have where each line represent a study, ours, of course, from the top. And each box represent the size of the sample. And to the degree that the box is further to the right, it indicates that the results favors more exercise. And virtually all studies seems to, with exception of a couple, generally support the benefit of aerobic exercise with small to medium effect sizes. In terms of looking at specific ingredients of what might impact the improvements, so we looked at a number of variables. One was training intensity. The other one is frequency of how many sessions people attended. And then the duration, how much time did they exercise across the study. And the training intensity is basically the variables that I described before, the time people spent exercising at their weekly target exercise zone. And what we found is that this was highly correlated. 0.7, obviously this is a very small sample, also needs to be replicated, but it looks very promising. On the other hand, frequency of sessions or duration seems to be less related, at least in our sample. Now, one other area that we looked at, and even though this was not the primary focus of the intervention, we looked at whether the aerobic fitness actually impacts social functioning rather than just neurocognition. In other words, whether the benefit extends to other functional abilities. And so this is the results that just published earlier, I mean, earlier this year, late last year. So what we found is that actually improvement in aerobic fitness significantly predicted enhancement in social functioning as indexed by self-report, by informants and by clinicians. Again, the informants are family members, typically that know the patient, that see them regularly. Clinician is just part of a clinical research interview. And the improvement predicted 47, 33, and 25% of the variance in social functioning, respectively. This is after controlling for a host of variables, including baseline demographics, medications, mood symptoms, as well as size of social networks. Now digging a little bit there, this is not unpublished data yet. We're preparing this. We looked at some, what might underlie this social functioning benefit. And it looks like it's operated primarily within the impact on emotional functioning, both in terms of emotional awareness. So improvement in aerobic fitness was highly correlated with improvement in social function. It was highly correlated with improvement in emotional awareness, which is a major predictor of social functioning. The emotional awareness here is basically patient's ability to label, identify and label emotions they are experiencing. The other variables that seems to be promising there is looking at emotion regulation. So this is reflected by decreased use of suppression, which is an emotion regulation strategy that tends to be less effective if used regularly. Based on this promising findings, we currently have a study that's looking at it on a multi-site single-blind randomized clinical trial, called the ICE project. The four-year study, we hope to recruit 200 subjects at four sites. The intervention is very similar. And again, this is by a generous grant from NIMH. Myself and Dr. Scott Strew from Columbia are the PI. So one of the things that I hope to, people get from this presentation is that some of the benefits that aerobic exercise can have and what we know so far from the literature and from studies is that aerobic exercise improves neurocognitive functioning, which is a major issue predicting functioning in general in people with SMI. There's some preliminary data suggest that this is extend also to social functioning, but we need more studies. As an intervention, exercise is relatively very safe. It is nearly side effect free. And that's not something, definitely medications, it's a major issue with antipsychotics. I think a big issue is that it's non-stigmatizing. A lot of the interventions that we do tend to have stigma to them, attached to them. And that takes away from our ability to disseminate them. Exercising, it's a common activity. Everybody does it. There's even a kind of a positive image attached to it. So this is a major, I think, component that in terms of potential for dissemination. It's relatively inexpensive and relatively easy to administer. This is something that can be administered at kind of any garden variety community mental health center. If you have a community room, you can definitely use that. Obviously having some equipment that's helpful, but it's not necessary. And this is, again, can be conducted both indoor and outdoor. Although again, I mean, in terms of outdoor, it depends on what part of the country you are. If you live in Texas in August, or maybe you're in Wisconsin, that would be a little bit more of a challenge, but definitely something that can be done indoor. We know it's providing multiple physical health benefits. So this is in addition to cognition and social functioning, you have a major cardiovascular benefits. And that's something I think that is unique to aerobic exercise compared to, for example, cognitive remediation that it adds, it's kind of one of those things that add a lot of benefits across the board from multiple domains. And again, I mean, I think in terms of literature, we have quite extensive literature that converge both from animal and human research studies that support the benefits of exercise. Now, one, I think critical issue that I think hasn't been discussed enough is that we don't have for severe serious mental illness, we don't have very modifiable risk factors. And actually poor or low aerobic fitness is actually one of the few modifiable risk factors for poor neurocognition and social dysfunction potentially and people with schizophrenia and other SMI. So this is something that could, we can definitely change a lot of other factors that we know as risk factors. We don't have an ability to change what is genetics or bread complications, et cetera. Now, this is something that is, excuse me, this is something that has been noted by many researchers and actually in Europe, the European Psychiatric Association published a couple of years ago, guidelines in a white paper that recommending the use of physical activity as a treatment for severe mental illness. And basically indicating that this is something that should be incorporated as part of standard treatment. Here are just kind of a couple of quotes. Our comprehensive review provides clear evidence that physical activity has a central role in reducing the burden of mental health symptoms in people with depression and schizophrenia. Our guidelines provide direction for future clinical practice. Specifically, we provide convincing evidence that it is now time for professionally delivered physical activity interventions to move from the fringes of healthcare to become a core component in the treatment of mental health conditions. So if you're listening to my presentation and reading these guidelines and you're hopefully excited about this, you're thinking, okay, how can I apply this to my patients? So a couple of practical suggestions from our experience, if you're thinking about incorporating aerobic exercise intervention. So obviously, and this is common sense, but many of our participants, many of our patients tend to have quite a sedentary lifestyle, multiple morbidities, physical, psychiatric. So they should undergo a physical examination by a physician to ensure that it's safe for them to exercise. Another issue is we use that strategy, and I think it's really important again, because people in this population tends to have very low aerobic fitness. So we use the start low and go slow strategy. And with some patients, it may be something as simple as, why don't you go walk around your block one time a day? And maybe, if they're able to do that, the second week, increase it to two blocks. Two blocks, go across, come back, and so forth. So gradually increasing it, making sure that people that participate are safe. Obviously, you need to keep consideration to local weather and available facilities. Another issue is consideration should be given to the size if you're using exercise groups. Many patients have concerns about body image issues. That's something that, if you put a lot of people together in a group, that issue may come up and may impact people's willingness to participate. So it's something important to kind of inquire and with participants. One last thing is exercise sessions should be led by and supervised by a certified trainer with background. Someone who has experience, who is a professional in terms of exercise. And preferably someone who has a background with clinical populations, although that's not necessary. But again, I mean, that's something that would go a long way. I think beyond just telling people, go and walk around the block. Now, in terms of technology, so there's a number of technologies that are out there that can be used to kind of gamify, so to speak. The exercise we use at the time, Xbox, so there's others today, Peloton, others, Mirror. One thing about the technologies is that they tend to move much, much faster than our studies when our studies kind of produce data. So it was like a typical five-year randomized clinical trial to look at an intervention. If you use a certain technology by the time the trial ends five years later, that technology may be obsolete or there's something much, much better. So I think rather than focus on a particular technology, I think it's like thinking about something that would be fun. And ultimately in terms of beyond the technology, beyond the effectiveness, the attendance part, and this is ultimately, I think, the challenge is making people participative, finding things that would be fun. And in our case, that was the Xbox again, but others are available as well. And I guess that will depend sometimes of your resources, your budget, your space, et cetera. But I think it's a challenge to get people exercise in general. And I think that's not different with people with SMI, but also people with SMI enjoy the same things that people without SMI enjoy. And a lot of these technologies are fun, and you can get a really good workout from them. So I would encourage people listening here today to explore those. And I'll stop at this point. Thank you very much for your attention. Thank you, Dr. Kim. Thank you for such an interesting presentation. Before we shift to Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Using the SMI Advisor app, you can access resources, education, and upcoming events. You can also complete mental health app rating scales and even submit questions. So you can download the app today at smiadvisor.org app. So to jump into questions, Dr. Kimby, again, I think you covered so much wonderful ground for the newest research practical tips. One of the first questions, if I'm a clinician and I'm trying to explain the benefits of exercise and sort of cognition, what are the things I can tell my patient that will get better or worse? And if I'm a clinician and I'm trying to explain the benefits of exercise, what are the things I can tell my patient that will get better or I'll see the most effect? Is it memory? Is it attention? Is it going to be focused? Or what does the evidence say and kind of tell them will be the thing they'll see improving the most in cognition? Well, generally, actually, the benefits seems to be kind of across the board. So there's, you know, that's the one of the nice thing about exercise that it seems to that it's not a particular just for memory or, you know, or just for, you know, executive functioning. So the literature is still unsettled about that, but it seems to be that at this point, it's like what we can conclude is that the benefits are across the board and they're not just for a particular domain. Got it. So that's a nice thing to tell patients. It's going to be really, if they have a cognition symptom, we can say this may be potentially something useful. Another question in you alluded to at the end is, how would you recommend I start an exercise regimen for a patient with serious mental illness who's been very sedentary, they maybe can't afford an Xbox and I've been telling them to walk. Is there an initial goal or how do you kind of start people on that exercise journey in a simple, meaningful way? Absolutely. That's a great question. I originally, and actually this is sort of this, my research in this line of work came from a work with a particular patient, which is exactly the type of patient you described. Someone who was in the forties, was very obese, very sedentary, did very little in terms of any kind of functioning. And this is being New York City. So I suggested to her that she would just walk around her block, sort of just the four, and so their block and do it once a day. And the goal was, I mean, I think at that point, she could have done more, but I was actually purposely trying to make it almost sort of foolproofs that minimize the chances that she would fail or discontinue. And I think initially you wanna create a, it's helpful to create a pattern of success that patients are able to stick with a routine that you're prescribing. So I asked her to do it for a week and she came back and reported that she was able to do that. And then I suggested, well, maybe we can increase it a little bit if that sounds good to you. And she agreed and we settled on two blocks. So essentially she'll walk two blocks across and then come back two blocks and across. And she did that for a week. And then making long story short, we increased it by a block every week. And over the course of about 18 months, she got to the point that she was doing 40 blocks per day. That became part of her routine. She lost a lot of weight. Her diabetes got much better. Other factors in terms of health kind of improved. It was a very slow and gradual process, but at the same time, I think that's something that the patient felt comfortable and safe and kind of knew what the plan is that I'm not gonna push them too much. And it's also, that's something that's kind of done in collaboration. Each time I ask her, does that make sense to you? Is that too much? Is kind of, am I pushing you too much? And I think that kind of really helped in terms of feeling that this is a joint process. And after a time, she started to actually noticing the benefits. So the motivation was very much there. And so it sounds like a lot of shared decision-making and careful attention. Related questions. Some of your slides kind of were talking about heart rate and kind of as people are doing aerobic exercise, it perhaps is more intense than walking. Is it, if someone's asking, is it okay if my patients are doing, they're being active, but they're not getting their heart rate up as high? Or what is the difference between low and we'll call it higher heart rate exercise? I think pretty much any kind of activity that makes your heart run would benefit. I mean, obviously the more intensive ones tends to have, there's a biological cascade that comes from that, that produce, for example, for BDNF, generally it's the 60% of maximal heart rate. But 60%, again, just for a reference, 60% maximal heart rate, it's basically it's a moderate intensity exercise, which is the equivalent of being able to walk and talk at the same time. So you should be able, you're not gonna be out of breath enough to not be able to talk while walking. So that's a fairly modest intensity. But again, it's a bit on the side of a brisk walk, but not necessarily intensive in any way. So, and I think once you start to get to the 60% of maximal heart rate region, then there's additional benefits there. But the benefits again, we know for mood, it's helpful for cognition, for social functioning, obviously cardiovascular. So there's no need for people if they're not ready, for it to do sort of something more intense. I mean, in our case, people did that, but it was very, very gradual over the course of 12 weeks. And then also it was supervised. We had a trainer during all session. So that was, I think that's a critical point. Okay, now that's a good thing. Because sometimes I think when people think exercise, they think sweating and it's more walk and talk is a good way that I think we can all explain it to folks and help them understand. And this is an interesting question, comment from the audience saying, I'm hopeful that by doing again, walk and talks with clients, instead of meeting them in the office and slowly increasing the distance walk, we can accomplish better treatment outcomes. Have you seen that people kind of doing sessions, be it kind of therapy or kind of visits with physical activity as part of it? Absolutely. I think there are some anecdotal reports about that. I think there's nothing wrong with it. I mean, I think you can do that too. I mean, I think, but if you're a trainer that has a caseload of 40 patients, I think you're gonna do a lot of walking or running. So that's gonna be a bit difficult. But I think for particular patients that might, I don't think there's anything wrong with that of joining a patient if that's seemed advisable. So yes. And then this is a question saying, I run an act team in a rural area and says, our folks cannot afford a gym or don't have one easily available. Do you think pedometers or step counters could be positive motivators? And if so, can you help me think of what is a number or target I should be telling people to think about? Well, I think that's a great idea. And again, I mean, that's the nice thing about exercise that you, I mean, it's very nice to have all this technology and it's very helpful if you have access to it, but that's not the case for many people. But you can still exercise outside, again, weather permitting. So I think pedometers or there's different devices that kind of sensor that measure steps and other activity. So I think it's a way to definitely to monitor and potentially, again, if you, some of them are actually fairly cheap so that you could get some basic devices to provide to patients and try to see whether this is something that they may consider starting to use. And hopefully over time, that's making them more conscious about how sedentary are their life are. Yeah. Is there, someone is asking, do you have a favorite pedometer or watch or smartwatch or device, or do you think they're all equally useful? Generally, they're all equally useful. I mean, there are some of them kind of more fancier and you have the iWatch that kind of tends to integrate with many more other activities, but there's also some basic designs that are also, will do the job in terms of the counting steps and sort of some basic characteristics of, basic characteristics of physical activity. Got it. And then a different question says, in your research on kind of using things like the Xbox or video games to get people active, did you find it worked best in any population? Was it perhaps younger adults or older adults? Was it male, female, or who would you target or offer that to? I think someone's wondering if they wanted to implement it. Who is the best population to get early success with? This is actually a great question because initially when we did this, there was not a lot of information whether this is something that would be feasible. And we had our concerns, but it turned out that, like I said, patients with schizophrenia like the same things that people without schizophrenia like. And this is kind of gamifying exercise and the patients really liked it. I mean, one thing that we did is we presented it, it wasn't sort of mandatory. We had sort of traditional exercise equipment, the treadmill, the elliptical machine, et cetera. And we had a couple of those consoles for active play video game and we introduced both to patients at the beginning of our exercise training. And so there was no pressure to use it. But what we find is pretty much across the board, there's no young or old. I think young people are more familiar with the system, but mostly for kind of more passive sort of kind of games, not for exercise, but even for elderly individuals or people that are much older, there was not an issue. So I think the nice thing it's like, this is something that everybody can enjoy. That makes sense. And the next question I think we know the answer to, but did anyone using your technology or systems who had schizophrenia ever get worried or paranoid about using technology systems as part of their care? No, actually again, and that was a concern. So we spent quite a bit of time thinking about how to introduce it in a way that will make people comfortable with this. And a part of it is that the choice of making it optional to use it, I think was a big part of it. So we let people decide on the first day of exercising, okay, you can use the treadmill, you can use this Xbox. If you wanna use the Xbox, we can show you how that works. Also patients coming in, they would see other patients using the equipment. So I think that kind of helped once we started. And again, the way you set it up, I think obviously you don't wanna put any kind of a PHI or any kind of information there. So we use card numbers. There's no any kind of identity critical information. They're just put like a number for each. So each person basically had a number when they logged in into the system. So it was, and again, we did not have any issue with people that maybe you would concern about paranoia. We had one issue with one patients that probably the one that we had in the study that had the highest disorganization score on our baseline that he had some difficulties following the instructions, but that was again, one patient out of 33 in that pilot. But so he was a little bit more frustrated with that, but otherwise I think for the vast majority of patient that was not an issue. That makes sense. And again, I think across all technology systems, I think people always have a concern, but I think the answer generally seems to be, as you said earlier, whether you have serious mental illness or not, people are interested in and use technology. People are people. This question says, and I'll actually. Just one last one point about it, because I think actually there's some benefits for using whether it's mobile technology, phones or any of these technologies is that patients may see other people use it. They are aware that other people are using it. And then you offer them the opportunity to use this sort of shiny, sexy technological device and they're able to use it and master to use it. And that actually can result in some kind of benefits in terms of people feeling good about themselves beyond the sort of the actual outcomes of just being able to master a technology. So I think there's an element of that as well. That makes sense. I've had a couple of questions. And I can combine with the one saying, this is about mobile, or kind of any mobile apps you like. And I'll just, from my own experience, when I've talked to my patients about apps, a lot of folks anecdotally that I've worked with have kind of been using an app called the Six Minute Abs Workout. And they said, John, we want to get really good abs. Doesn't that make sense? Who doesn't want good abs? We don't want to use a mood tracker. We want to use this kind of fitness app. Have you seen fitness apps that you, without endorsing any, that you think are good, or just any thoughts on these kind of fitness apps? I'm a bit biased in terms of, for exercise, I think what works best is having a trainer. And I think that the literature supports that. I think it's great if somebody can develop a schedule and doing it on their own, that's great. But I think this is also something that a lot of people in general, aside of SMI, having, that's a challenging population, issue for many people in America, evidently. So I think having a trainer, it helps in a long way. And also in terms of kind of safety, at least when people start at the beginning, because of the major comorbidities, I think it's probably better to have somebody start with a trainer that can start them kind of start low and go slow. And once they have that, they can potentially expand into using, and there's many, many apps out there, as you may know. Some of them are very good. I've used a few of them, again, without endorsing. So I think that's definitely a benefit, but I think I would say probably more for a significant minority of participants, but for most people, probably a trainer would be a better route. No, it does make sense. Engagement is hard around any behavior change, especially perhaps physical activity too. Someone is asking, related to that, are you able, if an clinician prescribed exercise must get something like a trainer covered, or have you seen kind of any efforts by different insurance? Again, realizing everyone has different plans, but it could be for people or people with disabilities. I think you're kind of coming in and out a little bit, but I think the question is about whether there's any kind of reimbursement or insurance plans that sort of support this kind of work. Yes, exactly. Okay. I am not aware of any. I mean, I know not specifically for SMI. I think that's probably the biggest barrier now for implementation is that whether this will be recognized as an intervention that is helpful and beneficial. I know there's a lot of insurance companies that sort of, but this is kind of like the general public that try to encourage people to exercise, and there's various incentives to do that, from gym membership to others. And it's getting definitely better in the past couple of years, but I think in terms of mental health treatment, no, we don't have that. And I think that's actually probably the biggest barrier to make it sort of disseminating this in a broad way. Excellent. One last question. Someone says, do you know of any good group interventions for older populations that are sedentary? So group interventions for older populations. Again, I mean, if you have older population, obviously, again, having a trainer that's sort of familiar with that population and being able to design some interventions that are then, but again, I mean, these interventions that, what we describe are not limited to a particular age. This is, so, I mean, I think any kind of physical activity, and it depends also when you say old, depends how old. But I think anything from as basic as group walk to, you know, people go walk in, if there's a park or any kind of area around your facility that can be used, that would be great, weather permitting. But also indoors, there's, you know, if you have a good trainer, they'd be able to devise intervention for that population and people with that kind of background. So I think, again, I mean, I think the critical thing here is this is, you know, a serious intervention and it requires knowledge. And I think you want to have a professional that knows what they're doing when they, when they, you know, executing this kind of an intervention. That makes sense. And now I'll actually switch us to our consult slide because I realize we've had so many good questions. We're very short on time. So if you have any follow-up questions about this topic or any related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. These consults are free and confidential. And SMI Advisor is just one of many SAMHSA initiatives. They're designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on mental health, addiction, prevention, TTCs, as well as the National Center of Excellence for Eating Disorders and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opiate epidemic. Thank you, Dr. Kimby, so much for sharing your expertise with us. Thank you all, everyone, for tuning in. Until next time, take care. Thank you.

Dr. David Kimby

aerobic exercise

serious mental illness

neurocognition

working memory

processing speed

pharmacotherapy

cognitive remediation

gamify exercise

Xbox Kinect