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Psychische Erkrankungen treten sehr häufig auf und gehen mit starken persönlichen und gesamtgesellschaftlichen Beeinträchtigungen einher. Zu den häufigsten psychischen Erkrankungen in Deutschland zählen depressive Störungen, Angststörungen und Insomnie. Sie treten häufig komorbid untereinander und mit anderen Störungsbildern, wie beispielsweise der Aufmerksamkeitsdefizit- /Hyperaktivitätsstörung (ADHS), auf. Die hohe Komorbidität könnte ein Hinweis darauf sein, dass diese Erkrankungen durch geteilte zugrundeliegende (transdiagnostische) Mechanismen entstehen und aufrechterhalten werden. Um diese Erkrankungen gleichzeitig wirksam behandeln zu können, braucht es daher Interventionen, die diese transdiagnostischen Mechanismen beeinflussen. Sportinterventionen können die Symptome von depressiven Störungen, Angststörungen, Insomnie sowie ADHS wirksam reduzieren. Wissenschaftliche Befunde weisen darauf, dass die Wirksamkeit über verschiedene Störungsbilder hinweg damit begründet werden kann, dass sportliche Aktivität eine positive Wirkung auf die Fähigkeit zur adaptiven Reaktion auf Stressoren (adaptive Stressbewältigung) haben kann. Maladaptive Stressbewältigung hingegen kann die genannten psychischen Erkrankungen bedingen und aufrechterhalten. Sportinterventionen scheinen nachhaltig wirksam zu sein, wenn sie Teilnehmende dazu befähigen langfristig sportlich aktiv zu sein und Sport bewusst gegen negativen Affekt (inklusive Stress) einzusetzen. Die Annahmen bezüglich der störungsbildübergreifenden Wirksamkeit von Sportinterventionen bzw. der transdiagnostischen Wirkmechanismen beruhen jedoch lediglich auf theoretischen Überlegungen, Longitudinal- bzw. Querschnittsstudien und experimentellen Studien mit gesunden oder störungsspezifischen Stichproben. Darüber hinaus gibt es wenige experimentelle Studien, die Wirkmechanismen von Sportinterventionen mit Mediationsanalysen untersucht haben. Daher kann geschlussfolgert werden, dass die störungsübergreifende Wirksamkeit von Sportinterventionen und deren transdiagnostischen Wirkmechanismen noch nicht ausreichend untersucht wurden. Dies ist jedoch wichtig, um die Wirksamkeit von Sportinterventionen zu verbessern und auf die Bedürfnisse diagnostisch heterogener psychischer Erkrankungen anzupassen. Es gibt es außerdem kaum Langzeitstudien von Sportinterventionen, die es erlauben, valide Aussagen über langfristig wirksame Komponenten von Sportinterventionen zu treffen. Anhand der selbstentwickelten Sportintervention ImPuls testeten wir die kurz- und langfristige Wirksamkeit einer Sportintervention in einer diagnostisch heterogenen klinischen Stichprobe. Wir untersuchten transdiagnostische Wirkmechanismen, die der kurz- und langfristigen Wirksamkeit zugrunde liegen könnten. ImPuls integriert evidenz-basierte Komponenten für eine wirksame Symptomreduktion über verschiedene Störungsbilder hinweg. Wir nutzten Selbstberichte zu störungsspezifischer und globaler Symptomatik sowie zu transdiagnostischen Mechanismen. Außerdem wurde ein physiologischer Indikator für die Fähigkeit zur adaptiven Stressbewältigung (Herzratenvariabilität, HRV) eingesetzt. Zusammengefasst zeigen die Ergebnisse dieser Studie, dass eine Sportintervention gleichzeitig die störungsspezifische und globale Symptomatik von Depressionen, Angststörungen, Insomnie und ADHS verbessern kann (Manuskript 1). Diese Symptomverbesserung über alle Störungsbilder hinweg scheint durch eine Steigerung der sportlichen Aktivität (Manuskript 1) und insbesondere der Steigerung der adaptiven Stressbewältigung bedingt zu sein (Manuskript 2). Auch ein Jahr nach Interventionsende konnte die Symptomverbesserung und gesteigerte Sportaktivität aufrechterhalten werden. Verantwortlich für die langfristige Wirksamkeit scheint insbesondere das Lernen der bewussten Anwendung von sportlicher Aktivität als Affektregulation zu sein (Manuskript 3). Die vorliegende Arbeit erweitert den aktuellen Forschungsstand bezüglich des Einsatzes von Sportinterventionen als Behandlung bei psychischen Erkrankungen, indem eine diagnostisch heterogene klinische Stichprobe gewählt wurde und kurz- und langfristige transdiagnostische Wirkmechanismen mit robusten statistischen Methoden untersucht wurden. Die im Rahmen der Dissertation durchgeführte Studie weist auf die transdiagnostische und langfristige Wirksamkeit von Sportinterventionen hin, wenn die Intervention auf die Verbesserung der adaptiven Stressbewältigung abzielt und Teilnehmende dazu befähigt regelmäßige sportliche Aktivität als Affektregulations-Strategie zu nutzen. Stärken und Limitationen der Studie sowie praktische Implikationen der Ergebnisse werden in dieser Dissertation detailliert dargestellt. Es werden zudem relevante zukünftige Forschungsaufgaben diskutiert. Mental disorders occur very frequently and are associated with severe personal and social impairment. Depressive disorders, anxiety disorders and insomnia are among the most common mental disorders. They often occur comorbidly with each other and with other mental disorders, such as attention deficit hyperactivity disorder (ADHD). The high comorbidity may indicate that these disorders are caused and maintained by shared underlying (transdiagnostic) mechanisms. Therefore, to effectively treat these disorders simultaneously, interventions that beneficially impact these transdiagnostic mechanisms are needed. Exercise interventions can efficaciously reduce symptoms of depressive disorders, anxiety disorders, insomnia, as well as ADHD. Scientific evidence indicates that the efficacy of exercise interventions across diagnostically heterogenous mental disorders may be due to their potential to increase the ability to adaptively respond to stressors (coping). In contrast, maladaptive stress coping can cause and maintain the aforementioned mental disorders. Beneficial effects of exercise interventions seem to be maintained if they enable participants to exercise regularly in the long-term and to use exercise intentionally to reduce negative affect (including stress). However, these assumptions regarding the efficacy of exercise interventions across disorders and transdiagnostic mechanisms of action are based only on theoretical considerations, longitudinal or cross-sectional studies, and experimental studies with healthy or disorder-specific samples. Moreover, experimental studies are needed that investigate these mechanisms of action by the conduction of mediation analyses. Therefore, it can be concluded that the efficacy of exercise interventions across heterogenous diagnoses and their transdiagnostic mechanisms of action have not been sufficiently investigated. However, this is important to improve the efficacy of exercise interventions and to tailor them to the needs of diagnostically heterogeneous mental disorders. Furthermore, follow-up periods of exercise trials have been rarely conducted which limits valid assumptions about long-term efficacious components of exercise interventions. Conducting the self-developed exercise intervention ImPuls, we tested the short- and long-term efficacy of an exercise intervention in a diagnostically heterogeneous clinical sample. We examined transdiagnostic mechanisms of action that might underlie short- and long-term efficacy of exercise interventions. ImPuls integrates the most efficacious evidence-based components for symptom reduction across diagnostically heterogenous outpatients. We used self-reported measures to assess disorder- specific and global symptom severity as well as transdiagnostic mechanisms. We also used a physiological indicator of the ability to adaptively cope with stressors (heart rate variability, HRV). In summary, the results of this study demonstrated that an exercise intervention can simultaneously reduce disorder-specific and global symptom severity across depressive disorders, anxiety disorders, insomnia, and ADHD (Manuscript 1). Reductions of symptoms across all disorders seem to be due to an increase in exercise (Manuscript 1) and, particularly, an increase in the ability to adaptively cope with stressors (Manuscript 2). Symptom reductions and the increase in exercise were also maintained one year after the end of the intervention. Adopting the intentional use of exercise as an affect regulation strategy seems to underlie the long-term efficacy (Manuscript 3). The present dissertation extends the current state of research on the use of exercise interventions as a treatment for mental disorders by choosing a diagnostically heterogeneous clinical sample and examining short- and long-term transdiagnostic mechanisms of action with robust statistical methods. The study conducted in the context of this dissertation indicates transdiagnostic and long-term efficacy of exercise interventions when improvements of the ability to adaptively cope with stressors a major aim and when participants are enabled to use regular exercise as an affect regulation strategy. Limitations, strengths as well as future directions and practical implications of the present study are discussed in detail.

Hintergrund und Stand (inter)nationaler Forschung: Sportliche Aktivität hat einen positiven Einfluss auf die Symptomatik von Menschen mit psychischen Erkrankungen [ref:1]. Die Bewegungsintervention ImPuls soll sie darin unterstützen, ihre Symptomatik zu verbessern und sportliche [zum vollständigen Text gelangen Sie über die oben angegebene URL]

This research question is a part of the ImPuls study. The study protocol of the ImPuls study is published at https://doi.org/10.1186/s12888-021-03541-3 and registered in the German Clinical Trial Register (ID: DRKS00024152, 05/02/2021).

These research question is a part of the ImPuls study. The study protocol of the ImPuls study is published at https://doi.org/10.1186/s12888-021-03541-3 and registered in the German Clinical Trial Register (ID: DRKS00024152, 05/02/2021). We know from literature that there are a lot of variables that may have an impact on the symptom severity in a transdiagnostic sample of different mental disorders. In the following section we will shortly present possible impact factors that are also assumed to be mechanisms of change within the pragmatic randomized controlled trial (RCT). Physical activity (PA) and PA-related health competence (PAHCO). There is a body of evidence assuming that PA that is planned, structured and repeated, with the primary aim to improve or maintain physical fitness (Caspersen et al., 1985) might represent a preventive factor as well as an effective treatment in patients suffering from mental disorders. In a recently published RCT, an exercise intervention was efficacious in improving global symptom severity in a transdiagnostic sample (Zeibig et al., 2021). The results indicate that the reduction of global symptom severity was predicted by an increase in the amount of PA (Zeibig et al., 2021). Furthermore, exercise-specific affect regulation as part of PAHCO (Schmid et al., 2020) seemed to underly treatment effects (Zeibig et al., under review). Repetitive negative thinking (RNT). RNT defined as “a mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and the possible causes and consequences of these symptoms” (Nolen-Hoeksema et al., 2008) might be a transdiagnostic risk factor for severity of depression and anxiety (Spinhoven et al., 2018). Sleep quality. Sleep disturbance is a symptom of many axis I disorders, e.g. in posttraumatic stress disorder or depressive disorders. In fact, depressed patients who also suffer from insomnia report higher levels of symptom severity compared to depressed patients without insomnia (Sunderajan et al., 2010). Evidence that extends these results to patients with other psychiatric disorders indicate that impaired sleep quality is strongly associated with higher levels of psychiatric symptom severity, assessed by patients themselves and clinicians (Kallestad et al., 2012). Health-related quality of life (HRQoL). HRQoL describes the perceived physical and mental health of an individual over time and includes correlates of HRQoL as health risks, functional status and social support (Centers for Disease Control and Prevention, 2000). A general population survey revealed that depressive and anxiety disorders are associated with the poorest outcome of HRQoL (Saarni et al., 2007). Regarding symptom severity, HRQoL seems to be negatively correlated among depressive patients (Cao et al., 2013) and patients suffering from post-traumatic stress disorder (Nachar et al., 2013) as well as from insomnia (Kyle et al., 2010). Perceived stress. Stress is defined as situations “in which environmental demands, internal demands, or both, tax or exceed the adaptive resources of an individual, social system, or tissue system” (Monat & Lazarus, 1991). Acute stressful life events or chronic levels of stress are a risk factor for a broad range of mental disorders such as posttraumatic stress disorder, depression, insomnia and anxiety disorders (Basta et al., 2007; Smoller, 2016). At the same time, people suffering from mental disorders are more sensitive to stress and experience higher levels of stress than healthy people (Connor et al., 2007; Zorn et al., 2017). However, research regarding symptom severity in a clinical sample is still pending. Fear of the corona virus (FoC). During the Covid-19 pandemic, people were confronted with a new, fast-spreading virus that was associated with high mortality rates, lack of treatment methods and overstrained health systems (Meyerowitz-Katz & Merone, 2020; Wiersinga et al., 2020). This situation was associated with high FoC in the population (Luo et al., 2021) and first results suggest that FoC is positively associated with symptom severity in depression and anxiety disorders (Belen, 2021; Fink et al., 2021; Rogers et al., 2021). Emotional regulation (ER). ER is defined as the “extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goal” (Thompson, 1994). Deficits in ER may favor the development of depression (Berking et al., 2014) and among patients suffering from depression deficits are seen as one key factor in the maintenance of symptoms (Ehring et al., 2010). In turn, enhancing ER skills using specific interventions may reduce symptom severity in depressive patients (Radkovsky et al., 2014). Emotional intelligence (EI). EI is defined as „the ability to process your emotions and others’ emotions to guide your thinking and behavior” (Ahmed Okasha et al., 2022) and impaired EI is seen as one principal component in depressive disorders (Fisher et al., 2010). Thus, research implies that impaired self-perceived EI is correlated with symptom severity among depressive patients (Ahmed Okasha et al., 2022). Sociodemographic data. Among a representative adult German sample, the prevalence of common mental disorders (e.g. depression or anxiety disorders) is higher among females, except for substance use disorders (Klose & Jacobi, 2004). Furthermore, being single, separated, divorced or widowed as well as being unemployed is associated with an increased risk of any mental disorder. Regarding the prevalence of depressive or anxiety disorders, no age effects were found (Klose & Jacobi, 2004) and higher education seems to yield lower rates of mood disorders (Alonso et al., 2004). However, research regarding symptom severity in a clinical sample is still pending. To summarize we can say that there are various variables associated with symptom severity of different mental disorders. However, they are mainly investigated in disorder-specific samples which is not in line with growing evidence supporting transdiagnostic treatments in patients with mental disorders (Dalgleish et al., 2020). Thus, research regarding impact factors on global symptom severity in a transdiagnostic sample is necessary. These results could provide important information that could be used to create transdiagnostic therapy approaches focusing on those impact factors with the highest impact on global symptom severity.

Everyday people are confronted with the perception of stress caused by several problems and challenges. These so-called stressors reach from long lists of tasks at work over the car traffic at rush hour up to social conflicts at home. Furthermore, crises of world affairs such as the Covid-19 pandemic are additional stressors, associated with a high prevalence of stress among the general population (Salari et al., 2020). Stress is defined as situation “in which environmental demands, internal demands, or both, tax or exceed the adaptive resources of an individual, social system, or tissue system,” (Monat & Lazarus, 1991). Acute stressful life events or chronic levels of stress are a risk factor for a broad range of mental disorders such as posttraumatic stress disorder (PTSD), major depressive disorder (MDD), Insomnia and anxiety disorders (Basta et al., 2007; Smoller, 2016). At the same time, people suffering from mental disorders are more sensitive to stress and experience higher levels of stress than healthy people (Connor et al., 2007; Zorn et al., 2017). Therefore, these mental disorders are also called stress-related disorder (Smoller, 2016). Stress does not necessarily lead to the development of a mental disorder, but it is generally associated with a lower quality of life (QOL) (Chaudhury et al., 2018). QOL is defined as the “individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHOQOL, 1998, p. 1570). According to a systematic review the negative association between stress and QOL becomes even stronger if people also suffer from disorders such as sleep disorders, burnout or depression (Ribeiro et al., 2018). However, studies mainly compared stress and QOL from samples consisting of individuals with a specific mental disorder with healthy controls (Berghofer et al., 2020; Zorn et al., 2017). Although both constructs are shared relevant factors across all stress-related disorders, there is a gap in data from transdiagnostic analyses. One part of this study is therefore to fill this gap. Physical activity (PA), which is “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 128), has a contrary effect to stress on mental health in that it directly reduces the experience of stress but also elevates mood and increases QOL not only in healthy people but also in people suffering from mental disorders such as depression or anxiety disorder (Penedo & Dahn, 2005; White et al., 2017). The latter mechanism is attributed to the so-called stress-buffering hypothesis. According to this hypothesis, the increase, or a reduced decrease – compared to stronger decreases – in characteristics such as QOL is due to a reduction in the negative impact of stress (Gerber & Puhse, 2009). In one of the studies investigating the effect university students with more PA have been shown to be more satisfied in life and having higher positive affect than the group with lower levels of PA although they were confronted with the same academical stressors during this period (Wunsch et al., 2017). However, there is a lack of data on this hypothesis with regard to people suffering from mental disorders as – to our knowledge – it has only been tested on healthy people with provoked or naturally occurring stressors or people with physical diseases (Giessing et al., 2021; Klaperski & Fuchs, 2021; Schilling et al., 2020). Especially in terms of the underlying transdiagnostic mechanisms already mentioned, the idea of a stress buffer through PA does not seem to have been explored yet. Hence, this context gives rise to tow objectives for this study. In a first step we want to show that stress and QOL can be seen as underlying transdiagnostic factors in people with stress-related disorders. We expect higher levels of stress among the transdiagnostic sample and we also suspect that this group shows lower QOL due to the negative association of these two factors than the matched healthy sample. The second and also the main aim of this study is to shed light on the impact of PA on the association between stress and QOL in a transdiagnostic sample of people suffering from depression (mild, severe), insomnia, post-traumatic stress disorder and/or panic disorder (with or without agoraphobia).

Additional file 1. TIDieR-Checklist.pdf (TIDieR Checklist).

Hintergrund: In Deutschland erhalten lediglich 10% aller Patienten mit psychischen Erkrankungen eine evidenzbasierte Behandlung [ref:1]. Die Wartezeiten auf einen Therapieplatz betragen im Durchschnitt ca. fünf Monate. Die Wirksamkeit ausdauerorientierter sportlicher Aktivität[zum vollständigen Text gelangen Sie über die oben angegebene URL], 19. Deutscher Kongress für Versorgungsforschung (DKVF)