Table 1 List of all included studies – Study characteristics

Attux et al. (2013) [31]

Brazil

Clinically stable outpatients with schizophrenia spectrum disorder

160

IG 36.2 (SD 9.9); CG 38.3 (SD 10.7)

12-week Lifestyle Wellness Program including one-hour weekly sessions to discuss topics like dietary choices, lifestyle, physical activity and self-esteem with patients and their relatives

TAU

0 M

3 M

6 M

QoL (World Health Organization Quality of Life Questionnaire (WHO-QOL-BREF))

Self-esteem (Rosenberg Self-esteem scale)

Living skills (Independent Living Skills Survey (ILSS))

Dietary fat and fibre intake (Dietary, Instrument for Nutrition Education (DINE))

Physical activity (International Physical Activity Questionnaire (International Physical Activity Questionnaire (IPAQ))

Smoking (Fagerström tolerance questionnaire)

No significant differences between groups in PROs

Baker et al. (2015) [32]

Australia

Smoking outpatients with schizophrenia spectrum or bipolar disorder, or other psychotic disorders

235

41.6

(SD 11.1)

9-month face-to-face lifestyle intervention including one 90-min session and a total of 16 one-hour sessions to discuss topics like smoking cessation and other CVD risk behaviours such as physical activity and healthy eating habits

Telephone-based intervention with discussions on comparable topics, but less intensive

0 W

15 W

12 M

HRQoL (12 item Short Form survey (SF-12)

QoL Impact of Weight on Quality Of Life (IWOQOL-lite))

Depression symptoms (Beck Depression Inventory (BDI-II)

Weekly activity in walking and sitting (IPAQ)

Daily servings of vegetables, fruit, or combined (24 h eating habits recall)

Smoking (Fagerström test for nicotine dependence; Opiate Treatment Index (OTI); Self-reported cigarettes per day; Smoking abstinence)

Readiness and Motivation to quit smoking (RQM)

Alcohol and cannabis use (OTI)

No significant differences between groups in PROs

Bartels et al. (2013) [33]

USA

Outpatients with schizophrenia spectrum, bipolar or major depressive disorder

133

43.8 (SD 11.5)

12-month In SHAPE Lifestyle intervention including weekly one-hour sessions with a fitness trainer with combined nutrition and health education plus a fitness club membership

One year of fitness club membership and education

0 M

3 M

6 M

9 M

12 M

Physical activity (International Physical Activity Questionnaire - Short-form (IPAQ-SF)),

Readiness to change dietary behaviour (Weight Loss Behaviour–Stage of Change Scale (WLB-SOC))

Significant differences between groups in improvements in readiness to engage in nutrition behaviours (WLB-SOC), minutes exercised per week, total vigorous activity score (IPAQ) at 12-month follow-up

Bartels et al. (2015) [34]

USA

Outpatients with schizophrenia spectrum, bipolar or major depressive disorder

210

43.9 (SD 11.2)

12-month In SHAPE Lifestyle intervention including weekly one-hour sessions with a fitness trainer with combined nutrition and health education plus a fitness club membership

One year of fitness club membership and education

0 M

3 M

6 M

9 M

12 M

18 M

Physical activity (International Physical Activity Questionnaire - Short-form (IPAQ))

Readiness to change dietary behaviour (Weight Loss Behaviour–Stage of Change Scale (WLB-SOC))

Dietary behaviour (Brief Block Food Frequency Questionnaire (FFQ))

Significant differences between groups in improvements in readiness to change nutrition behaviours (WLB-SOC), exercise minutes and total vigorous activity score (IPAQ) at 12-month follow-up, maintenance of effects at 18-months with exception of decreases in WLB-SOC in IG relative to CG

Battaglia et al. (2013) [35]

Italy

Outpatients on a stable antipsychotic pharmacological program with schizophrenia spectrum disorder

18

IG 36.0 (SD 5.0); CG 35.0 (SD 4.0)

12-week exercise intervention program including two-hour soccer training sessions twice a week

TAU

0 W

12 W

HRQoL (Short Form Health Survey (SF-12))

Significant differences between groups in improvements in the physical and mental domain of the SF-12 scores at 12-week follow-up

Bersani et al. (2017) [36]

Italy

Clinically stable inpatients with schizophrenia spectrum, bipolar or major depressive disorder

32

IG 52.6 (SD 13.7); CG 52.0 (SD 13.4)

5-week psychoeducational intervention including 90-min weekly sessions discussing topics like sleep, physical activity, diet and the consequences of voluptuary habits

Five psycho- educational group sessions discussing clinical outcomes or watching and discussing movies on pharmacological therapy

0 W

5 W

Sleep quality (Pittsburgh Sleep Quality Index (PSQUI)),

Physical activity (International Physical Activity Questionnaire (IPAQ)),

Adherence to the Mediterranean Diet (QUMDA)

Significant differences between groups in improvements in sleep quality (PSQUI) and adherence to diet (QUMDA) at 5-week follow-up

Bonfioli et al. (2018) [37]

Italy

Outpatients in community psychiatric services with affective or non-affective functional psychosis disorders

325

IG 44.6 (SD 10.3); CG 47.5 (SD 10.8)

6-month intervention program including seven one-hour health education group sessions discussing physical activity and diet, weekly one-hour group walking sessions and regular calls promoting adherence

TAU

0 M

6 M

Physical activity and dietary habits (Progressi delle Aziende Sanitarie per la Salute in Italia (PASSI))

Significant differences in improvements between groups in physical activity (PASSI) at 6-month follow-up

Brar et al. (2005) [38]

USA

Clinically stable long-term inpatients and outpatients with schizophrenia spectrum disorder

71

IG 40.0 (SD 10.1); CG 40.5 (SD 10.6)

14-week behavioural treatment intervention including 20 sessions teaching behavioural techniques for weight loss

TAU

0 W

4 W

8 W

14 W

End-point

Client satisfaction (Client Satisfaction Questionnaire (CSQ-8))

Significant differences in improvements between groups in client satisfaction (CSQ-8) at endpoint (endpoint unclear)

Brown & Chan [39]

(2006)

UK

Outpatients from a community mental health team with primary ICD-10 diagnosis of psychosis, major affective illness or severe personality disorder

28

IG 45.1; CG 41.7

6-week lifestyle intervention including weekly, 50 min, one-to-one health promotion sessions discussing topics like weight control, healthy eating, exercise, structured daily activity and substance misuse

Waiting-list (TAU during study period)

0 W

6 W

Dietary habits (Dietary Instrument for Nutrition Education (DINE))

Physical activity (GODIN questionnaire)

Psychological health (Hospital Anxiety and Depression scale (HAD))

Self-rated physical health, physical fitness and mental health (Self-reported Likert scale)

Alcohol use (Not specified)

Smoking (Not specified)

Significant differences between groups in improvements in moderate exercise (GODIN) at 6-week follow-up

Erickson et al. (2006) [40]

USA

Outpatients with schizophrenia spectrum, bipolar or posttraumatic stress disorder with psychotic symptoms

122

IG 49.7 (SD 6.9); CG 49.6 (SD 9.1)

12-month Lifestyle Balance behavioural intervention program including weekly classes and individual counselling for 8 weeks, food and exercise diaries, rewards, caregiver consultations, and monthly booster classes and counselling

TAU provided with self-help materials for weight loss, exercise and nutrition

0 M

2 M

6 M

12 M

Insight (Self-appraisal of Illness Questionnaire (SAIQ))

Motivation (Motivational Interview to Assess Stage of Change (MI))

No significant differences between groups in PROs

Evans et al. (2005) [41] Australia

Outpatients with schizophrenia spectrum, bipolar or major depressive disorder

51

IG 34.6 (SD 9.6); CG 33.6 (SD 11.6)

3-month nutritional intervention program to prevent weight gain including six one-hour education sessions discussing dietary components and physical activity

TAU (passive nutritional education from the booklet)

0 M

3 M

6 M

QoL (Not specified)

Overall health

Body image

Activity level (All self-report scales based on Clinical Global Impressions (CGI))

Significant differences between groups in improvements in subjective quality of life, overall health, body image, and activity level (CGI) at 3-month follow-up

Fernandez Guijarro et al. (2019) [42]

Spain

Outpatients from community mental health centers with schizophrenia spectrum, bipolar or major depressive disorder

61

47.0 (SD 9.2)

24-week nurse-led lifestyle modification program including weekly group sessions discussing lifestyle-related topics and booklets with information on various lifestyle topics

TAU

0 M

6 M

Overall health status (Euro-QoL (EQ-5D))

Smoking Fagerström tolerance questionnaire

Physical activity and sitting time (International Physical Activity Questionnaire – Short Form (IPAQ-SF))

Significant differences between groups in improvements in physical activity and sitting time (IPAQ-SF) and overall health (EQ-5D) at 6-month follow-up

Forsberg et al. (2010) [43]

Sweden

Patients living in supported housing with schizophrenia, bipolar disorder or other psychotic or psychiatric disorders

41

IG 39.8 (Range 23-59);

CG 42.8 (Range 22-71)

12-month health intervention programme consisting of two-hour study circles twice a week, once a week for diet sessions and once a week for physical activities

Aesthetic study circle to learn and practice artistic techniques

0 M

12 M

HRQoL (Study 36 Item Short Form (SF-36))

QoL (The Manchester Short Assessment of Quality of Life (MANSA))

Psychiatric symptoms (Symptom Check List (SCL-90-R))

Sense of coherence (SOC-scale)

Significant differences between groups in improvements in sense of coherence (SOC scale) between groups at 12-month follow-up

Gaughran et al. (2017) [44]

UK

Outpatients from community mental health teams with established psychotic disorder

406

44.2 (SD 10.12)

9-month IMPACT lifestyle intervention including 30-min sessions using motivational

interviewing techniques to address lifestyle choices, with modules targeting key lifestyle components

TAU

0 M

12 M

15 M

HRQoL (36-Item Short Form Health Survey (SF-36))

Smoking (Fagerström Nicotine Dependence Questionnaire) Alcohol use (Alcohol Use Disorders Identification Test (AUDIT))

Cannabis and illegal substance use (Time Line Follow Back)

Dietary habits (Dietary Instrument for Nutrition Education (DINE))

Physical activity (International Physical Activity Questionnaire – Short Form (IPAQ-SF))

No significant differences between groups in PROs

Goldberg et al. (2013) [45]

USA

Veterans from outpatient mental health clinics with schizophrenia spectrum, bipolar disorder, major depressive, or severe anxiety disorder

109

52.0 (SD 9.1)

6-month MOVE! intervention program including psychoeducation on dietary components, with weekly 60-min sessions for the first four months, followed by four biweekly sessions, and two individual sessions

TAU (plus basic information about diet and exercise every month)

0 M

6 M

HRQoL (12-Item Short Form (SF-12))

QoL Impact of Weight on Quality of Life Survey (IWQOL))

Dietary habits (Block Fruit, Vegetable, and Dietary Fat Screeners)

Physical activity (Not-specified)

Attitude and motivation (Diet and Exercise Confidence Survey)

No significant differences between groups in PROs

Ho et al. (2016) [46]

China

Inpatients residing in a mental health rehabilitation hostel with chronic schizophrenia

153

54.0 (SD 8.4)

3-month intervention program including weekly 60-min exercise classes for 12 consecutive weeks and twice-weekly 45-min practice sessions (IG1)

IG2 Tai-Chi intervention; CG Waiting-list (TAU during study period)

0 M

3 M

6 M

Perceived stress (Chinese perceived stress scale (PSS))

Daily functioning (Chinese version of the Barthel’s Activities of Daily Living (ADL) index; Lawton’s Instrumental Activities of Daily Living Scale (IADL))

Significant improvements in daily functioning (ADL) in IG1 compared to CG at 3 months

Holt et al. (2019) [47]

UK

Outpatients in community mental health trusts with schizophrenia spectrum disorder or first episode psychosis

414

IG 40.0 (SD 11.3); CG 40.1 (SD 11.5)

12-month STEPWISE intervention aimed at weight loss including four weekly 2.5-h group sessions discussing dietary and physical activity components complemented with three booster sessions and individual support contact

TAU with printed advice on lifestyle and risks associated with weight gain

0 M

3 M

12 M

Dietary intake (Adapted Dietary Instrument for Nutrition Education questionnaire (DINE))

HRQoL (RAND SF-36)

QoL (EQ-5D-5L)

Health beliefs (Adapted Brief Illness Perception Questionnaire)

Depressive symptoms (9-item Patient Health Questionnaire (PHQ-9))

Smoking status (Not specified)

No significant differences between groups in PROs

Jakobsen et al. (2017) [48]

Denmark

Outpatients with schizophrenia spectrum disorder or persistent-delusional disorder

428

38.6 (SD 12.4)

12-month CHANGE lifestyle program including lifestyle coaching consisting of weekly one-hour individual meetings supporting and motivating physical activity, healthy dietary choices and smoking cessation (IG1)

IG2 Care coordination; CG TAU

0 M

12 M

24 M

QoL (Manchester Short Assessment of Quality of Life (MANSA))

Physical activity (Physical Activity Scale (PAS))

Smoking (Fagerström Test for Nicotine Dependence)

Dietary habits (24-h recall interview & Food Frequency Questionnaire)

Perceived health (Likert scale)

No significant differences between groups in PROs

Kaltsatou et al. (2015) [49]

Greece

Inpatients with schizophrenia recruited from psychiatric outpatient department

31

59.9 (SD 14.1)

8-month supervised exercise training programme with Greek traditional dancing, 3 times/week

TAU (sedentary control)

0 M

8 M

QoL (Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q))

Significant differences between groups in improvement in overall QoL and subscales physical health, subjective feelings, household duties, leisure activities, social relationships and general activities at 8-month follow-up

Kwon et al. (2006) [50]

South Korea

Outpatients from clinical centres with schizophrenia or schizoaffective disorder

48

IG 32.0 (SD 9.2);

CG 29.8 (SD 6.1)

12-week weight management program based on diet and exercise management, once/week and after week 4 every other week

TAU with verbal recom-mendations as to their physical activity and eating behaviour

0 W

4 W

8 W

12 W

QoL (World Health Organization Quality of Life (WHO-QOL-BREF))

Eating inventory (Not specified)

No significant differences between groups in PROs

Looijmans et al. (2019) [51]

Netherlands

SMI patients from community-care and sheltered-living teams with psychotic disorders, mood disorders, personality disorders or anxiety disorders

244

46.1 (SD 10.8)

12-month multimodal, patient-centred lifestyle intervention to improve patients’ cardio-metabolic health delivered by mental health nurses, once every two weeks

TAU (Routine Outcome Monitoring assessment)

0 M

6 M

12 M

Patient readiness to change physical activity

Patient readiness to change dietary behaviour (Both stages of change model, 5 point Likert-scale)

Significant differences between groups in improvement of readiness to change eating behaviour at 6- and 12- month follow-up, but none in readiness to change PA

Marzolini et al. (2009) [52]

Canada

Patients from an Assertive Community Treatment (ACT) team with severe schizophrenia/ schizoaffective disorder

13

44.6 (SD 3.0)

12-week, community-based, group exercise program of either aerobic training twice/week (IG1)

IG2 resistance training;

CG TAU

0 W

12 W

Emotional functioning (Mental Health Inventory (MHI))

No significant differences between groups in PROs

Masa-Font et al. (2015) [53]

Spain

Outpatients from public mental health teams with schizophrenic, schizoaffective or bipolar disorder

332

IG 46.3 (SD 8.9);

CG 47.1 (SD 9.9)

3-month physical activity and diet educational group program, twice/week

TAU

0 M

3 M

HRQoL (36-Item Short Form Health Survey (SF-36))

Physical Activity (International Physical Activity Questionnaire (IPAQ))

Dietary habits (Mediterranean Diet Assessment Tool (PREDIMED)

Significant differences between groups in improvement of physical activity and in the physical component of SF-36 at 3-month follow-up

Mauri et al. (2008) [30]

Italy

Outpatients with bipolar disorder, schizoaffective disorder, or psychotic depression

49

38.9 (range 19-60 years)

24-week psychoeducational program (PEP) for weight loss based on a dietary program, eight monthly meetings total

No intervention, but continuing olanzapine, after 12 weeks starting PEP

0 W

12 W

24 W

QoL (Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF))

No significant differences between groups in PROs

McCreadie et al. (2005) [54]

Scotland

Schizophrenic patients living on their own or in supported accommodations

102

45 (SD 13)

6 months of free fruit and vegetables supported by instruction in meal planning and food preparation (IG1) or free fruit and vegetables alone (IG2)

TAU

0 M

6 M

12 M

18 M

Number of portions of fruit and vegetables eaten per week (Scottish Health Survey Questionnaire)

Significant improvements in fruit and vegetable intake in both IGs compared to CG after 6 months, decrease in consumption back to baseline in IG2 and more gradually in IG1 after 12 months

McKibbin et al. (2006) [55]

USA

Patients from board-and-care facilities and day treatment programs with schizophrenia or schizoaffective disorder

64

IG 53.1 (SD 10.4);

CG 54.8 (SD 8.2)

24-week Diabetes Awareness and Rehabilitation Training, weekly sessions addressing diabetes education, nutrition, and lifestyle exercise

TAU plus brochures from the American Diabetes Association relevant to diabetes management

0 M

6 M

Diabetes self-efficacy (Diabetes Empowerment Scale)

Dietary habits (Block Brief 2000 Revision of the Health and Habits and History Questionnaire)

Physical activity (Yale Physical Activity Scale (YPA))

Significant differences between groups in improvements in diabetes self-efficacy, physical activity, and reductions in fat consumption and trend toward greater percentage of calories derived from protein sources at 6 months follow-up

Mota-Pereira et al. (2011) [56]

Portugal

Outpatients with treatment-resistant non-remitted Major Depressive Disorder

33

IG 48.7 (SD 2.3);

CG 45.3 (SD 3.1)

12-week exercise program of moderate home-based walks, five times/week, once per week supervised plus usual pharmacotherapy

TAU (usual pharma-cotherapy)

0 W

4 W

8 W

12 W

Depression severity (Beck Depression Inventory (BDI-II))

Significant differences between groups in improvements in depression severity (BDI-II) at 12 week follow-up

Muralidharan et al. (2020) [57]

USA

Outpatients with schizophrenia, schizoaffective disorder, affective psychoses, post-traumatic stress disorder

276

IG1 53.7 (SD 9.6); IG2 54.7 (SD 8.9);

CG 54.2 (SD 9.9)

6-month in-person ‘MOVE’ weight management intervention, 24 group and/or individual sessions including psychoeducation, goal-setting, and weekly weigh-ins (IG1)

IG2 Online-delivered ‘MOVE’;

CG TAU

0 M

3 M

6 M

Mental health treatment outcomes (Revised Behaviour and Symptom Identification Scale (BASIS-R))

Loneliness (Three-Item Loneliness Scale)

QoL (Lehman Quality of Life Interview - Brief Version; Impact of Weight on Quality of Life (IWQOL-Lite))

HRQoL (Veterans RAND 12 Item Health Survey (VR-12))

Significant improvements in loneliness and mental health related quality of life at 6 months at IG1 (in-person); significant improvements in mental health-related quality of life at 3 and 6 months, and in weight-related self-esteem at 6 months in IG2 (web-based)

Ryu et al. (2020) [58]

South Korea

Outpatients from psychiatric units and community mental health centres with schizophrenia or schizoaffective disorder

60

IG 38.7 (SD 10.1); CG 39.0 (SD 8.6)

16-week group-based supervised and structured outdoor cycling program, 90 min/week

Occupational therapy

0 W

4 W

8 W

12 W

16 W

Depression severity (Beck Depression Inventory (BDI))

State anxiety (State and Trait Anxiety Inventory (STAI))

Self-esteem (Rosenberg Self-Esteem Scale (RSES))

QoL (World Health Organization Quality of Life (WHOQOL-BREF))

Physical Activity (Physical Activity Scale for the Elderly – Korean version (K-PASE))

Significant differences between group improvement of state and trait anxiety levels (STAI), and depressive symptoms (BDI) at 16 week follow-up

Silva et al. (2015) [59]

Brazil

Patients from mental health clinics with schizophrenia

47

IG1 33.4 (SD 12.2); IG2 32.9 (SD 2.3);

CG 33.6 (SD 2.6)

20-week program of concurrent exercise twice a week (IG1)

IG2 resistance exercise;

CG Occupational therapy

0 W

10 W

20 W

HRQoL (36-Item Short Form Health Survey (SF-36))

Significant improvements in the role-physical domain of SF-36 in both IGs compared to CG at 20 week follow-up

Skirnar et al. (2005) [60]

USA

Patients from inpatient, partial hospitalization and outpatient units or community treatment centres with psychotic or mood disorders

30

IG 39.7 (SD 8.2); CG 36.3 (SD 11.3)

12-week healthy lifestyle and fitness intervention, exercise session four times/ week and health seminars once/week

Waiting-list (TAU during study period)

0 W

12 W

Psychiatric symptoms (Symptom Checklist-90-R (SCL-90-R))

QoL (Lehman Quality of Life Questionnaire; SF-36)

Self-efficacy/ Empowerment (Boston University Making Decisions Questionnaire)

Significant differences in improvements of general health (Lehman questionnaire) and self-efficacy (Boston University questionnaire) at 12 week follow-up

Speyer et al. (2016) [61]

Denmark

Outpatients with schizophrenia, schizoaffective disorder or persistent delusional disorder

428

38.6 (SD 12.4)

12-month CHANGE lifestyle coaching plus care coordination plus treatment as usual (IG1)

IG2 Care coordination only;

CG TAU

0 M

12 M

Physical activity (Physical Activity Scale (PAS))

Smoking (Fagerström Test for Nicotine Dependence)

Dietary habits (Dietary Quality Score)

QoL (EQ-5D; Manchester Short Assessment of Quality of Life (MANSA))

Perceived health (Not specified)

Perceived stress (Perceived Stress Scale (PSS))

No significant differences between groups in PROs

Stiekema et al. (2018) [62]

Netherlands

Patients in sheltered housing or clinical care facilities with psychotic disorders, personality disorder or mood disorders

814

48.6 (SD 12.5)

12-month ELIPS diet-and-exercise lifestyle intervention targeting the obesogenic environment, several times intensive contact and activities during first 3 months, followed by 9 months monitoring phase

TAU

0 M

3 M

12 M

QoL (Manchester Short Assessment of Quality of Life (MANSA))

Significant reduction in quality of life (overall) in the intervention group after 3 and 12 months follow-up (between group differences MANSA in favour of the CG)

Sylvia et al. (2019) [63]

USA

Patients with bipolar disorder type I or II

38

42.0 (SD 12.3)

20-week ‘NEW Tx’ intervention, integrated CBT-based lifestyle intervention CBT-based with main modules nutrition, exercise, and wellness, weekly sessions (18 total)

Waiting-list (TAU during study period)

0 W

10 W

20 W

Physical activity (Exercise Questionnaire (EQ))

No significant differences between groups in PROs

Usher et al. (2013) [64]

Australia

Outpatients from local mental health services including NGOs with schizophrenia, bipolar disorder, or other psychotic disorders

101

NA.

12-week nurse-led weight management and exercise intervention, weekly sessions of health education and group physical activity

12-week healthy lifestyle booklet

0 W

12 W

Subjective effects of neuroleptic medications (Drug Attitude Inquiry-10 (DAI-10); Liverpool University Neuroleptic Side Effect Rating Scale)

HRQoL (Medical Outcomes Study Short Form 36 (SF-36))

No significant differences between groups in PROs

Yarborough et al. (2016) [65]

USA

Outpatients in community mental health centres with schizophrenia spectrum disorders

200

47.2 (SD 10.6)

12-month STRIDE Weight Loss and Lifestyle Intervention, 6 month weekly group meetings on nutrition and PA, 6 months monthly meetings maintenance phase

TAU

0 M

6 M

12 M

24 M

Body Image (Body Weight, Image and Self-Esteem Evaluation questionnaire (B-WISE))

General health (SF-36v2 general health subscale)

Health related self-efficacy (Patient Activation Measure (PAM))

Significant differences between groups in improvements in body image (B-WISE) at 12 and 24 months, and for general health (SF-36) and health related self-efficacy (PAM) at 24 months follow-up