Those of you who are familiar with The Reach Approach will be aware that for more than a quarter of a century we have been talking about the role of nutrition in mental health.
In fact our whole model is built around the relationships between mind, body, spirit and environment. We have long championed the view that mental health cannot be achieved without affording respect to all four of these elements. So although we know from our own research and clinical experience that nutrition can have a life-changing impact on the individual we would equally say that nutrition alone is only part of the solution.
In the article presented below, which we enthusiastically endorse, there is at long last some acknowledgement of the link between our food, brain health and our emotional and psychological states. This is a huge step in the right direction because as psychotherapists, nutritionists and holistic practitioners, we acknowledge that food and nutritional supplementation are critical ingredients in achieving good mental health.
So please read and where appropriate share this message with interested parties. There appears to be a mental health revolution taking place in the developed world and now diet is beginning to be taken seriously, let’s also see if we can get mind, spirit and environment to be equally factored in to a template that will promote good mental health and well-being for us all.
Nutritional medicine in mainstream psychiatry – Lancet Psychiatry 2015; 2: 271-74
Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefits in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional deficiencies) and mental health, and for the select use of nutrient-based supplements to address deficiencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging field of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.
Pharmacologically focused approaches have achieved a moderate reduction in the worldwide burden of poor mental health; however, indicators suggest that the burden of disease attributable to mental disorders will continue to rise worldwide during the coming decades.1,2 Mental disorders in general, and major depression and anxiety disorders in particular, account for a large burden of disability worldwide.2 Rapid urbanisation, and an overall transition from traditional lifestyles (concerning diet, physical activity, and social structures), which are some of the most pressing global and environmental issues of our time, have both been linked to increases in depression and other mental disorders.3 Indisputably, depression and other common mental disorders are already, and will probably become increasingly, part of an epidemic of comorbidity between physical and mental ill-health, with diet being a crucial common determinant.4
The current state, wherein populations in both developed and emerging economies preferentially consume nutrient-poor, energy-dense, highly processed foods, is historically unique – many people are both overfed and undernourished. Although caloric intake has increased, many individuals in affluent, developed nations do not meet the recommended intakes of several brain-essential nutrients, including B-group vitamins, zinc, and magnesium.5 Although slight improvements have been detected in the dietary intakes of sugar and fats between 2003-04 and 2009-10, documented intakes of nutrient-rich and fibre-rich vegetables and whole grains are far lower than recommended.6 These profound changes in dietary habits, along with tobacco use, insufficient physical activity, and harmful alcohol and recreational drug use, have resulted in an epidemic of ill health. The Major non-communicable diseases, along with mental disorders, are expected to cost the worldwide economy US $47 trillion from 2014 to 2020, if no substantial and effective action is taken.7
A traditional whole-food diet, consisting of higher intakes of foods such as vegetables, fruits, seafood, whole grains, lean meat, nuts and legumes, with avoidance of processed foods, is more likely to provide the nutrients that afford resiliency against the pathogenesis of mental disorders. The mechanisms by which nutrition might affect mental health are, at least superficially, quite obvious: the human brain operates at a very high metabolic rate, and uses a substantial proportion of total energy and nutrient intake; in both structure and function (including intracellular and intercellular communication), it is reliant on amino acids, fats, vitamins, and minerals or trace elements.3.8 Dietary habits modulate the functioning of the immune system, which also moderates the risk for depression.8 The antioxidant defence system, which is also implicated in mental disorders, operates with the support of nutrient cofactors and phytochemicals. Additionally, neurotrophic factors make essential contributions to neuronal plasticity and repair mechanisms throughout life, and these too are affected by nutritional factors.9
The purpose of this Personal View is to provide a platform for robust debate in the specialty, particularly regarding the need to move towards a new integrated framework in psychiatry, whereby consideration of nutritional factors should be standard practice. To provide a well-informed and respected consensus statement10 and viewpoint on this position, we formed an international collaboration of academic authors from members of the International Society for Nutritional Psychiatry Research (ISNPR). In this Personal View, we outline the supportive evidence underpinning the proposed paradigm shift, and present our perspective about the future direction of nutritional medicine in psychiatry.
In the past several years, links have been established between nutritional quality and mental health, and scientifically rigorous studies have made important contributions to the understanding of the role of nutrition in mental health. Many epidemiological studies, including prospective studies, have shown associations between healthy dietary patterns and a reduced prevalence of, and risk for, depression 11,12and suicide.13 Maternal and early-life nutrition is also emerging as a determinant of later mental health outcomes in children,14,15 and severe macronutrient deficiencies during crucial developmental periods have long been implicated in the pathogenesis of both depressive and psychotic disorders.16,17
A recent systematic review has now confirmed a relation between unhealthy dietary patterns and poorer mental health in children and adolescents.18 In view of the early age of onset for depression and anxiety, this data suggests that diet is a key modifiable intervention target for prevention of the initial incidence of common mental disorders. Indeed, although not statistically powered to assess the prevention of de-novo depression, results from the large European PREDIMED study19 showed a strong trend towards a reduced risk for incident depression for individuals randomly assigned to a Mediterranean diet with nuts, and this protective effect was particularly evident in those with type 2 diabetes. Similarly, results of an indicated prevention trial20 showed that dietary counselling was as effective as psychotherapy at prevention of transition to case-level depression in older adults. A randomised controlled trial designed to test the efficacy of dietary improvement as a treatment for major depression is underway.21
Convincing data suggests that select nutrient-based supplements (in isolation, or in combination),22 might provide many neurochemical modulatory activities that are beneficial in the management of mental disorders. Examples of these nutrient-based supplements include omega-3 fatty acids, S-adenosyl methionine (SAMe), N-acetyl cysteine (NAC), zinc, B vitamins (including folic acid), and vitamin D. Various clinical investigations support the potential usefulness of omega-3 fatty acids for disorders including, but not limited to, bipolar depression, post-traumatic stress disorder, and major depression, and they are indicated in the prevention of psychosis.23 Omega-3 fatty acids can provide a range of neurochemical activities via the following mechanisms: modulation of neurotransmitter (noradrenaline, dopamine, and serotonin) re-uptake, degradation, synthesis, and receptor binding; anti-inflammatory and anti-apoptotic effects; and the enhancement of cell membrane fluidity and neurogenesis via upregulation of brain-derived neurotrophic factor (BDNF).23,24
SAMe is an endogenous sulphur-containing compound that is an important neurochemical component involved in the one-carbon cycle responsible for the methylation of neurotransmitters that regulate mood. Clinical trials have shown that SAMe is an effective antidepressant,25and clinically significant augmentation effects occur with antidepressants.26 NAC has evidence of efficacy in bipolar depression, schizophrenia, trichotillomania, and other compulsive and addictive behaviours.27 This amino acid-based compound has glutamate modulatory effects, and anti-inflammatory, antioxidant, and neuroprotective activity.27 Zinc is an abundant trace element that is involved in cytokine modulation and hippocampal neurogenesis via upregulation of BDNF, and also modifies N-methyl-D-asparate and glutamate activity.28 Zinc deficiency has been linked to increased depressive symptoms, and evidence is emerging that zinc supplementation improves depressed mood, mainly as an adjunctive intervention with antidepressants.28
B vitamins are needed for proper neuronal function, and a deficiency of B9 (folate) has been reported in depressed populations, and in poor responders to anti-depressants.29 Several studies have assessed the antidepressant effect of folic acid with concomitant antidepressant use, and results of most either showed an increase in the proportion of participants who had an antidepressant response, or improved the onset of a response. Vitamin D is a neuro-steroid, with data suggesting that low maternal concentrations are implicated in schizophrenia risk, and deficiency is likewise linked to increased depressive symptoms.30 A combination of nutrients that match the natural physiological needs of the body, and also better represent the broad range of nutrients present in food, might prove even more effective than isolated nutrients alone.31
During the past several years, high-quality research into nutrition and mental health – a speciality that has been neglected – has grown rapidly and is finally starting to develop its potential. In view of the changes related to rapidly growing urbanicity and the globalisation of the food industry, resulting in profound shifts away from traditional dietary patterns, the ways in which overall diet and specific nutritional elements, multi-nutrient interventions, or both can affect mental health, clearly need to be identified. In view of the widespread use of nutrient supplements by individuals with and without mental disorders, scientifically rigorous methods should be used to assess the efficacy of these supplements and to identify what dose of a nutrient supplement is needed, by whom, when, and under what circumstances. From this resultant research, the evidence needs to be communicated to clinicians via educational programmes, and to the wider public via public health campaigns. Formal medical education should include training that focuses on the role of diet and nutrients in brain function and mental health.
Recommendations for governments to take more substantive actions to improve food quality and promote healthier dietary practices should be considered to address the substantial burden of disease that results from unhealthy diets. Importantly, the activities of the food industry need to be examined at a governmental level, and relevant policies need to be designed to reduce the worldwide burden of physical and mental ill health attributable to poor diet.4 Such policies are advised to stimulate substantial public change in dietary habits back towards a traditional whole-food diet (dependant on the culture). Further, better education of the public and clinicians about the role of nutrients in the brain and the link to mental health, is crucially needed.
Present treatment of psychiatric disorders can be improved and greater attention can be given to preventative efforts. As a result of the immense burden of mental disorders, modifiable targets to reduce the incidence of mental disorders are now urgently needed. Diet and nutrition offer key modifiable targets for the prevention of mental disorders, having a fundamental role in the promotion of mental health. Now its’ time for the recognition of the importance of nutrition and nutrient supplementation in psychiatry. Nutritional medicine should now be considered as a mainstream element of psychiatric practice, with research, education, policy and health promotion supporting this new framework.
JS, ACL, and FNJ drafted the initial version of this manuscript. All authors contributed intellectual content to the manuscript, and read and approved the final manuscript.
Jerome Sarris, Alan C Logan, Tasnime N Akbaraly, G Paul Amminger, Vicent Balanzá-Martinez, Marlene P Freeman, Joseph Hibbeln, Yutaka Matsuoka, David Mischoulon, Tetsuya Mizoue, Akiko Nanri, Daisuke Nishi, Drew Ramsey, Julia J Rucklidge, Almudena Sanchez-Villegas, Andrew Scholey, Kuan-Pin Su, Felice N Jacka, on behalf of The International Society for Nutritioal Psychiatry Research.
Declaration of interests
JS has received honoraria, research support, royalties, consultancy, or travel grant funding from Integria Health, Blackmores, Bioceuticals, Taki Mai, Pepsico, HealthEd, Soho-Flordis, Pfizer, Elsevier, the Society for Medicinal Plant and Natural Product Research, CR Roper Fellowship, and the National Health and Medical Research Council (NHMRC).
ACL has received consulting fees from Genuine Health (Toronto, Canada). VB-M has received grants, and served as consultant, adviser, or continuing medical education (CME) speaker during the past 3 years for the following entities: Angelini, AstraZeneca, Bristol-Myers-Squibb, Janssen, Juste, Lilly, Lundbeck, Otsuka, the Spanish Ministry of Science and Innovation, and Fundación Alicia Koplowitz. MPF has received funding for advisory board positions, or consulting, from: Takeda, Otsuka, Lundbeck, Genentech, Johnson & Johnson, and JDS Therapeutics; pending research support from Takeda; and for medical editing for DSM Nutritionals and GOED Omega-3. YM has received research support from the Japan Science and Technology Agency, National Centre of Neurology and Psychiatry (Japan), the Ministry of Health, Labour, and Welfare of Japan, and has been a paid speaker for Mochida Pharmaceutical Co, Takeda Pharmaceutical Company, Suntory Wellness, Eli Lilly Japan KK, Otsuka Pharmaceutical Co, and DHA & EPA Association. DM has received research support from the Bowman Family Foundation, Fisher Wallace, Nordic Naturals, Methylation Sciences, and PharmoRx Therapeutics. He has received honoraria for consulting, speaking, and writing from Pamlab, and the Massachusetts General Hospital Psychiatry Academy. He has received royalties from Lippincott Williams & Wilkins for the published book Natural medications for psychiatric disorders: considering the alternatives. TM has received research grants from the Japan Society for the Promotion of Science, the National Centre for Global Health and Medicine (Japan), the National Cancer Centre (Japan), the Ministry of Health, Labour, and Welfare of Japan, the Industrial Health Foundation, the Uehara Memorial Foundation, the Otsuka Pharmaceutical Co. DN has received research support from the Japan Society for the Promotion of Science and the Foundation for Total Health Promotion, and lecture fees from Qol Co, DHA & EPA Association, NTT DoCoMo, and Emotional Quotient Academy. AS has received funding from the Biotechnology and Biological Sciences Research Council (UK), The Australian Research Council, the NHMRC, the British Psychological Society, the Australian Wine Research Institute, Abbott Nutrition, Arla Foods, Bayer Healthcare, Cognis, Cyvex, GlaxoSmithKline Nutrition, Masterfoods, Martek, Naturex, Nestlé, Neurobrands, Sanofi, Verdure Sciences, and Wrigley, and received speaker fees from Abbott Nutrition, Barilla, Bayer Healthcare, Danone, Flordis, GlaxoSmithKline Healthcare, Kraft, Masterfoods, Martek, Novartis, Unilever, and Wrigley. K-PS has received research grants from the National Science Council, National Health Research Institute, and China Medical University in Taiwan, and joint research grants from the Royal Society (UK) and National Centre for Research and Development (Poland). FNJ has received grants and research support from the Brain and Behaviour Research Institute (USA), the NHMRC, Australian Rotary Health, the Geelong Medical Research Foundation, the Ian Potter Foundation, Eli Lilly, the Meat and Livestock Board Australia, and The University of Melbourne, and has been a paid speaker for Sanofi-Synthelabo, Janssen Cilag, Servier, Pfizer, Health Ed, Network Nutrition, Angelini Farmaceutica, and Eli Lilly.
1. Baxter A J, Patton G, Scott KM, Degenhardt L, Whiteford HA. Global epidemiology of mental disorders: what are we missing? PloS One 2013; 8: e65514.
2. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013; 382: 1575-86.
3. Logan AC, Jacka FN. Nutritional psychiatry research: an emerging discipline and its intersection with global urbanization, environmental challenges and the evolutionary mismatch. J Physiol Anthropol 2014; 33: 22.
4. Jacka FN, Sacks G, Berk M, Allender S. Food policies for physical and mental health. BMC Psychiatry 2014; 14: 132.
5. Parker E, Goldman J, Moshfegh A. America’s nutrition report card: comparing WWEIA, NHANES 2007-2010 usual nutrient intakes to dietary reference intakes. FASEB J 2014; 28 (suppl): 384.2.
6. Bowman S, Friday J, Thoerig R, Clemens J, Moshfegh A. Americans consume less added sugars and solid fats and consume more whole grains and oils: changes from 2003-04 to 2009-10. FASBE J 2014; 28 (suppl): 369.2.
7. WHO. Global action plan for the prevention of control of noncommunicable diseases 2013-2020. Geneva: World Health Organisation, 2013.
8. Berk M, Williams LJ, Jacka FN, et al. So depression is an inflammatory disease, but where does the inflammation come from? BMC Med 2013; 11:200.
9. Molendijk ML, Bus BA, Spinhoven P, et al. Serum levels of brain-derived neurotrophic factor in major depressive disorder: state-trait issues, clinical features and pharmacological treatment. Mol Psychiatry 2011; 16: 1088-95.
10. Sarris J, Logan A, Akbaraly T, et al. International Society for Nutritional Psychiatry Research consensus position statement: nutritional medicine in modern psychiatry. World Psychiatry (in press).
11. Lai JS, Hiles S, Bisquera A, Hure AJ, McEvoy M, Attia J. A systematic review and meta-analysis of dietary patterns and depressin in community-dwelling adults. Am J Clin Nutr 2014; 99: 181-97.
12. Psaltopoulou T, Sergentanis TN, Panagiotakos DB, Sergentanis IN, Kosti R, Scarmeas N. Mediterranean diet, stroke, cognitive impairment, and depression: a meta-analysis. Ann Neurol 2013; 74: 580-91.
13. Nanri A, Mizoue T, Poudel-Tandukar K, et al, and the Japan Public Health Center-based Prospective Study Group. Dietary patterns and suicide in Japanese adults: the Japan Public Health Center-based Prospective Study. Br J Psychiatry 2013; 203: 422-27.
14. Jacka FN, Ystrom E, Brantsaeter AL, et al. Maternal and early postnatal nutrition and mental health of offspring by age 5 years: a prospective cohort study. J Am Acad Child Adolesc Psychiatry 2013; 52: 1038-47.
15. Steenweg-de Graaff J, Tiemeier H, Steegers-Theunissen RP, et al. Maternal dietary patterns during pregnancy and child internalising and externalising problems. The Generation R Study. Clin Nutr 2014; 33: 115-21.
16. Brown AS, Susser ES, Lin SP, Neugebauer R, Gorman JM. Increased risk of affective disorders in males after second trimester prenatal exposure to the Dutch hunger winter of 1944-45. Br J Psychiatry 1995; 166: 601-06.
17. Susser ES, Lin SP. Schizophrenia after parental exposure to the Dutch Hunger Winter of 1944-45. Arch Gen Psychiatry 1992; 49: 983-88.
18. O’Neil A, Quirk SE, Housden S, et al. Relationship between diet and mental health in children and adolescents: a systematic review. Am J Public Health 2014; 104: e31-42.
19. Sánchez-Villegas A, Martínez-González MA, Estruch R, et al. Mediterranean dietary pattern and depression: the PREDIMED randomizes trial. BMC Med 2013; 11: 208.
20. Stahl ST, Albert SM, Dew MA, Lockovich MH, Reynolds CF 3rd. Coaching in healthy dietary practices in at-risk older adults: a case of indicated depression prevention. Am J Psychiatry 2014; 171: 499-505.
21. O’Neil A, Berk M, Itsiopoulos C, et al. A randomised, controlled trial of a dietary intervention for adults with major depression (the ”SMILES” trial): study protocol. BMC Psychiatry 2013; 13: 114.
22. Rucklidge JJ, Kaplan BJ. Broad-spectrum micronutrient formulas for the treatment of psychiatric symptoms: a systematic review. Expert Rev Neurother 2013; 13: 49-73.
23. Mischoulon D, Freeman MP. Omega-3 fatty acids in psyciarty. Psychiatr Clin North Am 2013; 36: 15-23.
24. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry 2012; 73: 81-86.
25. Sarris J, Papakostas GI, Vitolo O, Fava M, Mischoulon D. S-adenosyl methionine (SAMe) versus escitalopram and placebo in major depression RCT: efficacy and effects of histamine and carnitine as moderators of response. J Affect Disord 2014; 164: 76-81.
26. Papakostas GI, Mischoulon D, Shyu I, Alpert JE, Fava M. S-adenosyl methionine (SAMe) augmentation of serotonin reuptake inhibitors for antidepressant nonresponders with major depressive disorder: a double-blind, randomized clinical trial. Am J Psychiatry 2010; 167: 942-48.
27. Berk M, Malhi GS, Gray LJ, Dean OM. The promise of N-acetylcysteine in neuropsychiatry. Trends Pharmacol Sci 2013; 34: 167-77.
28. Lai J, Moxey A, Nowak G, Vashum K, Bailey K, McEvoy M. The efficacy of zinc supplementation in depression: systematic review of randomised controlled trials. J Affect Disord 2012; 136: e31-39.
29. Fava M, Mischoulon D. Folate in depression: efficacy, safety, differences in formulations, and clinical issues. J Clin Psychiatry 2009; 70: (suppl 5): 12-17.
30. Eyles DW, Burne TH, McGrath JJ. Vitamin D, effects on brain development, adult brain function and the links between low levels of vitamin D and neuropsychiatric disease. Front Neuroendocrinol 2013; 34: 47-64.
31. Rucklidge JJ, Johnstone J, Kaplan BJ. Magic bullet thinking – why do we continue to perpetuate this fallacy? [letter]. Br J Psychiatry 2013; 203: 154-55.