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According to Susan J. Noonan, MD, MPH, high nutrient-dense foods, like colorful fruits and vegetables, whole grains, beans, fish, poultry, and a small amount of olive oil and dairy can improve your patient's mood and lower their risk for depressive episodes. 

Keeping glucose levels steady may also help prevent mood swings. 

 is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do

 (December 2020). Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

A healthy diet can improve mood and effectiveness of antidepressant medications. Here's why your patients should be eating healthier. 

Food Is the Fuel

, despite significant decline in antipsychotic use in privately insured children since 2009, doctors continue to prescribe antipsychotic medication off-label for conditions not approved by the US Food and Drug Administration. These conditions include conduct disorder, attention-deficit/hyperactivity disorder, anxiety, and depression.

“We lack information on the effectiveness and safety of antipsychotics for treating those conditions in young children,” lead author Greta Bushnell, PhD, MSPH, a member of the Rutgers Institute for Health, Health Care Policy and Aging Research and an assistant professor at Rutgers School of Public Health, said to the press. “Guidelines recommend that psychosocial services are used before antipsychotic treatment and that children are carefully assessed before initiating antipsychotics. However, fewer than half of the children receiving antipsychotic treatment in our study had a visit with a psychiatrist or a psychotherapy claim.”

Journal of the American Academy of Child & Adolescent Psychiatry

, the study examined more than 300,00 antipsychotic prescriptions for privately insured children in the United States aged 2 to 7. The study also found antipsychotics were more often prescribed to boys aged 6 or 7.

“The low rate of use of safer first-line psychosocial treatments, such as parent-child interaction therapy or cognitive-behavioral therapy, potentially puts children at unnecessary risks associated with antipsychotic treatment,” Bushnell said to the press.

Risks associated with antipsychotic medication for children include weight gain, sedation, diabetes, high cholesterol, cardiovascular disease, and unexpected death.

The challenge for the future, the researchers concluded, will be improving antipsychotic prescriptions in young children.

1. Bushnell GA, Crystal S, Olfson M. Trends in Antipsychotic Medication Use in Young Privately Insured Children. 

https://www.jaacap.org/article/S0890-8567(20)31987-0/fulltext

2. Rutgers University. Prescriptions of Antipsychotic Medications in Young Children is Declining. News release. November 8, 2020. 

https://www.newswise.com/articles/prescriptions-of-antipsychotic-medications-in-young-children-is-declining?sc=dwhr&xy=5013482

Antipsychotic medications for young children are not being prescribed appropriately, according to a recent study. 

The Decline of Child Antipsychotic Medications

Over the past few decades, the level of sedentariness has increased and become a leading public health concern. Greater total sedentary time and longer sedentary bouts are associated with higher all-cause mortality risk.

 This is of even greater concern during the coronavirus 19 (COVID-19) pandemic, as the work force has changed dramatically with various institutions attempting to maintain their workers remotely.

The access to recreation centers and fitness facilities has decreased significantly for public safety purposes. This has made it particularly difficult to advise patients on how to pursue exercise. Yet, in psychiatry, we all prescribe exercise as a natural therapy to improve mood and manage depression and anxiety symptoms. There is a large body of evidence to suggest its benefits.

While most of us appreciate its importance, we also recognize that avoidance is exceedingly common. Too often patients hear the word 

 and develop an aversive reaction, as they anticipate that it involves intensive training reserved only for the athletically elite. So how can one simply and effectively counsel a patient on exercise to increase their chances of engagement?

The fact that exercise should be part of the treatment regimen for depression seems to be common knowledge, but it is important to emphasize studies from which this insight was formed. A large study of over 30,000 participants showed that 1 hour or more of exercise per week can prevent 12% of future cases of depression.

 Furthermore, 30 minutes of exercise on a stationary bike reduced depression symptoms 10 and 30 minutes post-exercise.

 Fascinatingly, these results are independent of the intensity of exercise.

While exercise has been reported to prevent depression and combat symptoms acutely, it has also been found to improve long term remission rates. One study found a reduction in depressive symptoms by 47% after 12 weeks of regular exercise.

 Another study showed that home-based exercise or supervised exercise resulted in statistically similar remission rates of major depressive disorder (MDD) as selective serotonin reuptake inhibitor (SSRI) use, albeit the sample size consisted more of those with mild depressive symptomatology.

 Even a year after study completion, the remission rates were correlated with the amount of regular exercise, with protective effects maximized at 180 minutes per week.

While the above studies focused primarily on aerobic physical activity, strength and resistance training can provide similar reductions in depression symptoms. A large meta-analysis of 33 randomized controlled trials showed that regular resistance training significantly reduced symptoms of depression.

 There is substantial improvement in mood by combining both aerobic physical activity and strength training.

 Strength training can reduce depression symptoms by 2 to 3 times that of the control group while also reducing bodily pain and improving vitality and social functioning.

 Furthermore, it is important to prevent obesity as it is strongly linked to increasing anxiety symptoms.

 Indeed, it is clear that regular exercise, both aerobic and strength training, can reduce the risk of developing depression, treat depression symptoms acutely, and provide long-term remission.

The exercise programs used in the aforementioned studies often included cycling on a stationary bike or the use of a treadmill. The participants used the bike or treadmill for 30 to 45 minutes

 with 1 study requiring the heart rate to achieve 75% to 85% of maximum heart rate reserve.

 Other studies simply relied on patients self-reporting weekly exercise, which included activities such as walking and swimming.

 Strength training regimens targeted large muscle groups and included exercises such as chest press, lat pulldown, leg press, leg extension, and knee flexion 2 to 3 times per week.

 Regardless of the type of physical activity, all exercise sessions lasted 45 minutes or less. Results were often intensity independent, suggesting that even 30 to 45 minutes of mild to moderate intensity exercise a few days a week is sufficient to improve mood symptoms.

While there is strong evidence that regular exercise can improve one’s mood, the clinician must prescribe exercise in a way that promotes adherence. Practical strategies include being specific with exercise routines, but also to listen to the patient’s preferences and barriers to exercise. These strategies will help formulate a program that the patient can maintain.

 It is also helpful to construct goal-oriented objectives that a patient can successfully achieve.

 In addition, it is beneficial to break larger exercise requirements into smaller, achievable chunks. Finding motivation is crucial, which can be done through strategies such as stressing the mood elevating properties of exercise or by encouraging social workouts. It has been shown that those who exercise with others more or equally as often than alone report greater self-health.

After condensing the information in the literature and combing it with strategies for compliance, we feel it is possible to come up with sample exercise prescriptions. For example, a patient with low exercise tolerance and motivation could be prescribed 30 minutes of moderate walking. The patient could start by walking 1 to 2 days a week and gradually increase to up to 6 days, which would equate to 180 minutes per week. If the patient is having a particularly hard time with motivation, the clinician can encourage walking with a friend and setting goals. In a patient who is aversive to aerobic activity, the clinician can prescribe strength and resistance training that focuses on large muscle groups. These strength sessions can be prescribed 2 to 3 times per week and up to 45 minutes per session. Exercises should target large muscle groups and include activities such as chest press, lat pulldown, leg press, leg extension, and knee flexion. If a patient does not have access to a fitness center or prefers home workouts, then they can perform exercises at home such as push-ups, air squats, wall-sits, and abdominal routines. Since the mood benefits of exercise have often been shown to be intensity independent, it is more than possible to work within the patient’s exercise tolerance and physical limits.

In addition, it can be beneficial to discuss with patients the neurobiological changes seen during exercise that may contribute to elevation of mood and improved cognition. Aerobic fitness is associated with greater hippocampal volume and memory performance.

 Exercise also increases performance in the area of executive functioning, which is attributed to greater function of the anterior cingulate and prefrontal cortices.

 Moreover, aerobic exercising upregulates brain-derived neurotrophic factor (BDNF)

, and acetylcholine neurotransmitter release

, all of which play a role in mood and cognition.

Resistance training has been shown to improve memory performance and verbal concept formation potentially through increased insulin-like growth factor-1 (IGF-1).

 Additionally, exercise training has shown to improve regional cerebral blood flow in sedentary older men.

 Endocannabinoids also play a role, as there is an increase in release during exercise which may contribute to some of the mood elevating effects.

 Certainly reviewing the neurobiological and cognitive alterations seen in exercise may aid in further justifying to the patient that physical activity can be as efficacious as psychopharmacotherapy. 

If approaching a formal discussion on exercise is relatively novel for a clinician, they could benefit from the use of the following SPORT mnemonic (Table 1). Furthermore, the NICE monoamine mnemonic (Table 2) can be used to lead the conversation around the neurobiological changes seen during exercise.

An exercise prescription is an important treatment option and a great adjunct to medications. The key is prescribing physical activity in a way that the patient will comply and remain engaged with. In psychiatry, we aim to improve our patient’s overall functioning biologically, psychologically, and socially. The various benefits of exercise extend well beyond improvement of mood. Applying the evidence and strategies discussed in this article will hopefully help reduce ambivalence in the patient and assist the busy clinician in implementing successful integration of exercise.

is a medical student at the Michael G. DeGroote School of Medicine, McMaster University.

is an assistant clinical professor at McMaster University and the Advanced Mind Clinic.

Do you incorporate exercise prescriptions in treatment strategies? Share you feedback: PTEditor@mmhgroup.com

1. Diaz K, Howard V, Hutto B, et al. Patterns of sedentary behavior and mortality in US middle-aged and older adults: A national cohort study

2. Chan J, Liu G, Liang D, et al. Special issue—Therapeutic benefits of physical activity for mood: A systematic review on the effects of exercise intensity, duration, and modality. 

3. Harvey S, Overland S, Hatch S, et al. Exercise and the prevention of depression: Results of the HUNT cohort study. 

4. Meyer J, Koltyn K, Stegner A, et al. Influence of exercise intensity for improving depressed mood in depression: A dose-response study. 

5. Dunn A, Trivedi M, Kampert J, et al. Exercise treatment for depression: Efficacy and dose response. 

6. Blumenthal J, Babyak M, Doraiswamy R, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. 

7. Hoffman B, Babak M, Craighead W, et al. Exercise and pharmacotherapy in patients with major depression: One-year follow-up of the SMILE study. 

8. Gordon B, McDowell C, Hallgren M, et al. Association of efficacy of resistance exercise training with depressive symptoms: Meta-analysis and meta-regression analysis of randomized clinical trials. 

9. Moraes H, Silveria H, Oliveria N, et al. Is strength training as effective as aerobic training for depression in older adults? A randomized controlled trial. 

10. Oftedal S, Smith J, Vandelanotte C, et al. Resistance training in addition to aerobic activity is associated with lower likelihood of depression and comorbid depression and anxiety symptoms: A cross sectional analysis of Australian women. 

11. Singh N, Clements K, Fiatarone M. A randomized controlled trial
of progressive resistance training in depressed elders. 

12. Amiri S, Behnezhad S. Obesity and anxiety symptoms: A systematic review and meta-analysis. 

13. Knapen J, Vancampfort D, Morjien Y, et al. Exercise therapy improves both mental and physical health in patients with major depression. 

14. Kanamori S, Takamiya T, Inoue S, et al. Exercising alone versus with others and associations with subjective health status in older Japanese: The JAGES Cohort Study. 

15. Chaddock L, Erickson K, Prakash R, et al. A neuroimaging investigation of the association between aerobic fitness, hippocampal volume, and memory performance in pre-adolescent children. 

16. Hillman C, Buck S, Themanson J, et al. Aerobic fitness and cognitive development: Event-related brain potential and task performance indices of executive control in preadolescent children. 

17. Seifert T, Brassard P, Wissenber M, et al. Endurance training enhances BDNF release from the human brain. 

18. Poulton N, Muir G. Treadmill training ameliorates dopamine loss but not behavioural deficits in hemi-parkinsonian rates. 

19. Blomstrand E, Perret D, Parry-Billings M, Newsholme E. Effect of sustained exercise on plasma amino acid concentrations on 5-hydroxy-tryptamine metabolism in six different brain regions in the rat. 

20. Fordyce D, Farrar R. Enhancement of spatial learning in F344 rats by physical activity and related learning-associated alterations in hippocampal and cortical cholinergic functioning. 

21. Tsai C, Wang C, Pan C, Chen F. The effects of long-term resistance exercise on the relationship between neurocognitive performance and GH, IGF-1, and homocysteine levels in the elderly. 

22. Kleinloog J, Mensink R, Ivanov D, et al. Aerobic exercise training improves cerebral blood flow and executive function: A randomized, controlled cross-over trial in sedentary older men. 

23. Sparling P, Giuffrida A, Piomelli D, et al. Exercise activates the endocannabinoid system. 

Exercise can be a useful tool in managing symptoms of anxiety and depression. Learn how you can integrate exercise prescriptions into your treatment plans. 

How to Effectively Prescribe Exercise

 by the University of the Basque Country (UPV/EHU) confirmed that gender is a significant determining factor in mental health and its management.

The university’s research group OPIK, Social Determinants of Health and Demographic Change, a multidisciplinary group comprising research personnel in the field of social and health sciences, discovered that not only are women more likely to receive diagnoses, they are also more likely to be prescribed medications.

“Women are more frequently diagnosed with depression and anxiety and the taking of prescribed psychotropic drugs is also significantly higher, even if there is no difference with men with respect to mental health equality, diagnoses, and frequency of visits to healthcare centers. All this could point to the existence of a medicalization process of mental health in women,” Amaia Bacigalupe, PhD, one of the authors, said to the press.

Data from the 12-item General Health Questionnaire (GHQ-12) pulled from 3 locations—Basque Autonomous Community (2018), Spain (2017), and the Spanish sample corresponding to the European Health Survey (2014)—were used to determine that there is a higher prevalence of mental health issues in women of all ages and social status. In 2017, the prevalence of poor mental health was approximately 23.4% in women and 15.6% in men. The frequency of diagnoses of depression or anxiety was also much higher in women, with 19.4% in women and 8.5% in men.

According to the data, there is also clear intersectionality on the different axes of inequality: gender inequalities in mental health tend to increase among the population of older age, lower social class, and lower educational level. Data consistently pointed out that mental health tended to worsen as living conditions did, with factors such as suffering from insufficient income, low educational level, manual social class, unemployment, or lack of social support as contributing factors.

Bacigalupe stated to press that policy intervention may be a cure for this gender gap: “All those policies designed to combat the discrimination endured by women on the labor market, in the responsibility for domestic and care work, in the use of time and, generally, relating to those that empower women on the basis of their greater political representation and making them more socially visible, will exert a positive effect on the reduction in mental inequalities between men and women.”

The researchers concluded that further studies are needed to gauge whether this is an over-medicalization process of women, or oppositely an underdiagnosis of men.

1. Bacigalupe A, Cabezas A, Bueno MB, Martín U. El género como determinante de la salud mental y su medicalización. Informe SESPAS 2020. 

https://www.sciencedirect.com/science/article/pii/S0213911120301813?via%3Dihub

2. University of the Basque Country. Depression and anxiety are more frequently diagnosed in women. News release. November 4, 2020. 

https://www.newswise.com/articles/depression-and-anxiety-are-more-frequently-diagnosed-in-women

A study in Spain uncovers the hard truth about gender inequality in mental health care. 

Are Women More Frequently Diagnosed With Anxiety and Depression?  

As the world has changed and the space a child can breathe and spread out in has grown smaller, environmental exposures to artificial light at night, noise, secondhand smoke, near-roadway air pollution, and other adverse health effects have only increased. A report in 

 looks at whether these exposures are linked to childhood psychosocial stress.

The report’s investigators ran a cohort study that included participants from the Southern California Children’s Health Study. The participants resided in 8 densely populated urban communities and responded to highly detailed questionnaires. Artificial light at night exposure was determined via utilized satellite images. Green space also used satellite technology. Noise levels were estimated using the US Traffic Noise Model. Near-roadway air pollution was established through a dispersion model. Stress was determined at ages 13 to 14 years and 15 to 16 years through the 4-item Perceived Stress Scale, with higher scores on the scale indicate a higher level of stress.

A total of 2290 children were recruited for the study. The researchers found that girls had higher perceived stress than their male counterparts with an average score of 5.7, whereas boys had an average of 4.9. As girls aged, their average stress score rose to 6.0, but boys’ score reduced to 4.7 as they aged. Multivariate mixed-effects models that examined multiple exposures found that exposure to secondhand smoke in the home was linked with a 0.85 increase in the score. When looking at factors in the physical environment, the researchers found that an interquartile range (IQR) increase in artificial light at night was tied to a 0.57 unit increase in the score together with a 0.16 score increase per IQR increase of near-roadway air pollution and a −0.24 score decrease per IQR increase of the enhanced vegetation index.

Interestingly, income appeared to modify the artificial light at night effect size estimate. The children who lived in households earning less than $48,000 per year were found to have significantly greater stress per IQR increase in artificial light at night. Additionally, sleep duration seemed to mediate, at least in part, the ties between stress and artificial light at night, as well as enhanced vegetation index.

The researchers concluded that exposure to a number of environmental exposures such as nighttime artificial light, secondhand smoke, and air pollution were linked to increased perceived stress in young adolescents. Availability of green space did helps ameliorate those associations.

1. Franklin M, Yin X, McConnell R, Fruin S. Association of the built environment with childhood psychosocial stress. 

How does a child’s physical living space impact their neurodevelopment? Can it cause them increased stress? 

Toll of Environmental Exposures on Teen Psychosocial Stress

 involving 2 million participants, people experiencing depression, anxiety disorder, or bulimia, are at heightened risk of excessive alcohol use.

Unhealthy alcohol use and psychiatric disorders frequently co‐occur, but understanding how the levels of alcohol consumption affect those with psychiatric disorders might provide valuable insight to health care providers. The study sought to learn more about these relationships.

Researchers used alcohol screenings from Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system, to collect data from a large, population‐based sample. More than 12 million alcohol screenings were conducted, which will help identify subgroups of patients with psychiatric disorders and co‐occurring unhealthy alcohol use.

Medical assistants asked 3 questions. One is a modified version of the National Institute on Alcohol Abuse and Alcoholism single‐item screening question used to determine whether the individual had drinking-heavy days: “How many times in the past 3 months have you had 5 or more drinks in a day?” The second and third are questions used to calculate average alcoholic drinks consumed per week: “On average, how many days per week do you have an alcoholic drink?” and “On a typical drinking day, how many drinks do you have?”

From these questions, patients were classified into 2 groups: low risk of alcohol abuse and unhealthy use. The unhealthy use class was further divided into subgroups: daily, where patients exceeded daily drinking limits; weekly, where patients exceeded weekly drinking limits; and both. Researchers then compared these answers to whether patients had a documented psychiatric disorder diagnosis, focusing on a list of 8 common psychiatric disorders: depression, bipolar disorder, anxiety disorder, obsessive compulsive disorder, schizophrenia, schizoaffective disorder, anorexia nervosa, and bulimia nervosa.

In the final sample of patients, it was found that the daily group was more likely to be male and aged 18 to 34 years old, while the weekly group was more likely to be female and aged 65 or older. The daily and weekly groups were more likely to have higher household incomes, greater than approximately $87,500. Those who reported no alcohol usage were more likely to be Asian, Native Hawaiian, or Pacific Islander. Those diagnosed with bipolar disorder or schizoaffective disorder were more likely to report no drinking, as well.

From this data pool, care management strategies for these patients can be formed, ideally for primary care settings. The findings support a need for screening for unhealthy alcohol use in primary care, which would help clinicians address alcohol problems early and help to prevent the onset of an alcohol use disorder.

1. Palzes VA, Parthasarathy S, Chi FW, Kline-Simon AH, et al. Associations Between Psychiatric Disorders and Alcohol Consumption Levels in an Adult Primary Care Population. 

Alcoholism: Clinical & Experimental Research.

https://onlinelibrary.wiley.com/doi/10.1111/acer.14477

2. Research Society on Alcoholism. Patients with Depression, Anxiety, and Bulimia at Heightened Risk of Unhealthy Drinking and Associated Health Issues. News release. November 2, 2020. 

https://www.newswise.com/articles/patients-with-depression-anxiety-and-bulimia-at-heightened-risk-of-unhealthy-drinking-and-associated-health-issues

A diagnosis of depression, anxiety disorders, or bulimia may also indicate a heightened risk of excessive drinking. 

The Intersection of Excessive Alcohol Use and Psychiatric Disorders 

Dr Daven Morrison talks about the myriad of issues surrounding the current complex workplace. 

is Assistant Clinical Professor of Psychiatry at Chicago Medical School.

Keeping up your energy at work is difficult with the stressors of COVID-19, social unrest, and the upcoming election. As a mental health professional, how can you help alleviate this fear? 

The Pervasive Fear of Going to Work

is the CEO of VistaGen Therapeutics, Inc.  

To see more of what VistaGen is doing to improve the medicinal treatments for anxiety and depression, see 

Benzodiazepines Hit With Boxed Warning by FDA

VistaGen Therapeutics CEO Shawn Singh discusses what he and VistaGen are doing to create and improve treatments that complement your practice. 

Complementing Your Psychotherapy 

The physical and psychological symptoms of anxiety, such as feeling tense or having trouble concentrating, can be so uncomfortable that they cause behavioral changes. How might these components play out in, say, a Presidential election?

7 Steps to Alleviating Election Anxiety

The US Food and Drug Administration (FDA) recently released a Drug Safety Communication (DSC) covering the risks of benzodiazepines, a drug commonly used for treating anxiety and other conditions.

“While benzodiazepines are important therapies for many Americans, they are also commonly abused and misused, often together with opioid pain relievers and other medicines, alcohol and illicit drugs,” said FDA Commissioner Stephen M. Hahn, MD in the FDA’s public announcement. “We are taking measures and requiring new labeling information to help health care professionals and patients better understand that while benzodiazepines have many treatment benefits, they also carry with them an increased risk of abuse, misuse, addiction and dependence.”

The FDA announced benzodiazepines will require the Boxed Warning, the most prominent of safety warnings, because current prescribing information does not adequately cover the risk and harmfulness of these medicines. The FDA is also requiring changes to several sections of the prescribing information. The following sections will need alterations: 

In the wake of this announcement, VistaGen announced its commitment to developing a new generation of medicines that will surpass current treatments for anxiety and depression.

“Considering the FDA’s new safety requirement for benzodiazepines, at a time where anti-anxiety medication is deeply needed, we believe our efforts to develop a new generation alternative to benzodiazepines is of critical importance,” said Shawn K. Singh, JD, chief executive officer at VistaGen Therapeutics in an email to subscribers.

VistaGen’s Phase 3 study will be randomized, double-blind, and placebo-controlled, with approximately 182 patients with social anxiety disorder involved. The study will be conducted by Michael Liebowitz, MD, professor of clinical psychiatry at Columbia University and director of the Medical Research Network in New York City.

1. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class: Includes potential for abuse, addiction, and other serious risks. US Food and Drug Administration. September 23, 2020. 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

Benzodiazepines, a drug used to treat anxiety and other conditions, has been mandated to alter their safety warnings. Read about the latest. 

Anxiety & Stress Disorders