Integrating Nutritional Guidance Into Psychiatric Practice

Poor nutrition has been linked to worsened mood, psychosis, cognitive impairment, neurodevelopmental disorders, and other psychiatric problems.¹ A bidirectional relationship exists between the gut-brain axis: the gut microbiota in the gastrointestinal tract produces neurotransmitters from the food we eat, which communicate through the enteric nervous system with the central nervous system, autonomic nervous system, and hypothalamic-pituitary-adrenal axis.² Therefore, an individual’s nutrition must be optimized in addition to other treatment modalities such as medication and therapy to maximize psychiatric health and well-being.

Recent studies have shown that ultraprocessed foods that frequently lack fiber, healthy fats, vitamins, and minerals account for more than 50% of the daily caloric intake for the average American, leading to mental and physical health problems such as metabolic disease.³ Lifestyle psychiatry emphasizes the importance of a whole-foods, plant-forward diet that is rich in vegetables, fruits, whole grains, legumes, nuts, and monounsaturated fats.⁴ A large body of evidence shows that adopting healthy dietary patterns such as the Mediterranean or Ornish diets can significantly improve mood, cognition, and other psychiatric symptoms.⁵ Introductory guidance around nutrition should therefore be considered another primary tool in the management of psychiatric disorders.⁶

Clinical Guidance

Beginning the conversation: food as a window into the patient’s world

Nutrition discussions can offer valuable insight into patients’ emotional lives, identities, and daily routines. Eating behaviors often mirror underlying feelings, revealing patterns of avoidance, control, neglect, or care. Rather than starting with calorie and macronutrient goals, clinicians can explore what food represents to the patient.

Open-ended questions such as “What does a typical day of eating look like?” or “When do you most enjoy food?” elicit both habits and the meaning behind them. Deeper questions such as “What does food mean to you?” or “Who do you usually eat with?” can uncover themes of belonging, independence, and vulnerability related to eating or body image. Table 1 provides sample questions for initiating these discussions in a warm, collaborative manner.

This approach aligns with the field of positive psychiatry, emphasizing agency and meaningful activity as therapeutic drivers.⁷ Reframing a meal as self-nourishment rather than restriction transforms eating into a small but potent behavioral intervention. This shift allows patients to experience self-efficacy, which can be especially valuable for those struggling with anhedonia or low motivation.

Assessing Nutritional Status

Clinicians often hesitate to assess nutrition due to time constraints or limited formal training; however, many screening tools are available, ranging from 2 to 30 minutes, that can help identify major deficits (Table 2). Our preference is the Rapid Eating Assessment for Participants–Short Form (REAP-S) because it is relatively quick and highlights deficiencies in macronutrients, which can easily be recommended.⁸

When glaring nutritional deficits are identified during screening, clinicians should consider obtaining laboratory tests to check for deficiencies in critical nutrients, particularly in 3 populations: older adults (vitamins B₆, B₉, B₁₂), pregnant women (iron and vitamin B₉), and patients with alcohol use disorder (vitamins B₁ and B₉, potassium, magnesium, and phosphorus).

If nutritional deficiencies are identified, encouraging patients to add a variety of colorful foods to their plate (“Eat the rainbow”)—through vegetables, fruits, legumes, nuts, and seeds—offers a practical and empowering path toward improved mood, energy, and cognitive health. Tables 3 and 4 summarize macronutrients and micronutrients most strongly linked to mental well-being, emphasizing natural dietary sources rather than supplements, whenever feasible.

Specific Nutrition Recommendations

Overwhelming evidence shows that a well-balanced Mediterranean-style diet can mitigate the symptoms of many mental health disorders, such as mood disorders, psychotic disorders, attention-deficit/hyperactivity disorder, intellectual disability, substance use disorders, and cognitive impairment.¹² However, certain conditions have been shown to worsen with specific nutrient deficiencies and can benefit from supplementation, including alcohol use disorder, pregnancy (for neurodevelopment of the fetus), early psychosis, and cognitive impairment (Table 5).¹³

Practical Strategies for Integrating Nutrition Into Psychiatric Visits

Brief, structured interventions can have a meaningful impact—particularly when framed as part of whole-person care.⁵ Motivational interviewing techniques are well suited to this process. For example, asking, “What change in your eating might help your energy or mood feel a little steadier this week?” invites reflection while conveying optimism. Reinforcing partial successes (“You made breakfast twice this week—that’s meaningful progress”) sustains momentum.

Practical strategies include the following:

1. Normalize the discussion: “Many patients notice that what they eat affects how they feel. Would it be OK if we talked about that for a few minutes?”
2. Start with 1 concrete goal: Choose a small, attainable step—such as eating breakfast, adding a fruit or vegetable each day, or cooking a single meal per week.¹⁴
3. Use visual anchors: Simple tools such as the MyPlate food guide, a hand portion guide, or a grocery list can make abstract goals tangible.^15,16
4. Track progress intentionally: Briefly review nutrition and other lifestyle goals during medication or therapy follow-ups, emphasizing that these behaviors are as essential to monitor as medication effectiveness or mood symptoms.¹⁷
5. Link to motivation and meaning: Invite reflection with a question such as, “If the way you eat could help your mind feel calmer or more energized, what’s 1 small step you’d want to try?” This phrasing combines gentle psychoeducation with collaborative goal setting, reinforcing hope and agency.

Collaboration with dietitians, primary care physicians, or endocrinologists further enhances continuity of care.¹⁸ Coordinated management—such as introducing metformin for antipsychotic-associated weight gain or adjusting antidepressant dosing alongside dietary change—maximizes synergy between behavioral and pharmacologic interventions.

Case Studies

Case 1: Lifestyle interventions to augment antidepressant response
“Alex,” a 40-year-old male delivery driver with major depressive disorder (Patient Health Questionnaire-9 [PHQ-9] score = 19), reported irritability, fatigue, and loss of motivation. He worked 10-hour shifts and lived with extended family, often returning home to chaos and conflict. Alex’s diet consisted mainly of hot dogs, chips, and sweets consumed on the road, with minimal fresh fruits or vegetables. Treatment began with psychopharmacology (escitalopram 10 mg daily) and weekly telehealth psychotherapy, reducing his PHQ-9 to a score of 12 after 6 weeks.

Nutritional lifestyle interventions were subsequently added to his treatment. A structured dietary review (Starting the Conversation tool) revealed strong links between his eating patterns, energy levels, and emotional well-being.¹⁹ Alex expressed sadness that he and his wife no longer cooked together, describing shared meals as something that once “made life feel calmer.”

His wife offered her support, and they agreed to cook together 3 evenings a week and to prepare portable, balanced snacks—vegetables with hummus, fruit, and roasted chickpeas—for his workday cooler. His therapist incorporated cognitive behavioral therapy and acceptance and commitment therapy principles to help him reframe beliefs about fairness and responsibility, emphasizing meal preparation as an act of connectedness and self-care rather than obligation.¹⁹

After 6 weeks, Alex’s PHQ-9 score decreased to 8, with steadier energy, improved concentration, and fewer sugar cravings. He described renewed satisfaction in small daily routines.

Clinical takeaway: Even modest dietary improvements—when linked to emotional meaning and connectedness—can reinforce antidepressant and psychotherapeutic gains, supporting more sustainable recovery in major depression.¹⁹

Case 2: Nutrition, connectedness, and cognition in late-life depression
“Susan,” an 82-year-old woman with mild neurocognitive disorder and major depressive disorder, presented with weight loss of 10 pounds, low motivation, and reduced attention. Living with her husband and adult daughter, Susan spent most of her day sitting in 1 room and frequently napping. Progressive hearing loss left her unable to follow family conversations at mealtimes, leading to frustration, withdrawal from shared meals, and less time in the kitchen—once a source of pleasure.

She reported skipping lunch and sometimes dinner, subsisting mainly on frozen meals and pastries. Breakfast with coffee was her only consistent meal. Laboratory test results revealed borderline B₁₂ (298 pg/mL) and folate (3.5 ng/mL) levels. Her nutritional decline appeared intertwined with social isolation and physical limitations from leg swelling that made standing while preparing meals difficult.

A referral to a dietitian led to a simple plan of fortified cereals, soups, and preportioned snacks labeled by day. Single-serving meals were designed that required minimal effort for Susan to prepare to reduce waste and support independence. Susan reported feeling encouraged by the dietitian’s approach. Her family also made small environmental changes—reducing background noise and cueing Susan during conversation—which made mealtimes more engaging. Additionally, her primary care physician prescribed B₁₂ supplements and monitored her levels.

After 2 months, her weight stabilized (she regained 7 lb), her energy improved, and she resumed activities she once enjoyed, such as gardening and playing cards.

Clinical takeaway: Early nutritional intervention can prevent decline in older adults with depression and cognitive impairment. Addressing social and sensory barriers at mealtime helps restore both nourishment and a sense of belonging.

Concluding Thoughts

The cases presented highlight that even small, tailored nutritional changes—whether supporting a couple in shared meal preparation or restoring structure for an older adult—can meaningfully enhance psychiatric outcomes. Across these examples, the common thread is collaboration—reframing nutrition not as a directive, but as a relational, strengths-based process that complements pharmacologic and psychotherapeutic care.

Despite these benefits, implementation often brings challenges. Barriers may stem from patient ambivalence, socioeconomic constraints, or clinician discomfort with discussing diet. Practical strategies include the following:

• For ambivalence: Use motivational interviewing to explore discrepancies, eg, “You want to feel less tired, and you’re wondering whether food might help.”
• For financial or mobility barriers: Emphasize low-cost, shelf-stable options such as canned beans, frozen produce, and oats.
• For cultural considerations: Encourage patients to identify nourishing foods within their own traditions rather than adopting unfamiliar diets.
• For clinician confidence: Seek continuing medical education modules, peer learning, or collaboration with registered dietitians and other medical specialists to expand comfort and credibility.

These strategies acknowledge that nutritional change, like other therapeutic interventions, unfolds within real-world constraints. When clinicians approach it collaboratively and with curiosity, barriers become opportunities for problem-solving and connection. Integrating nutrition into psychiatric care strengthens the biopsychosocial model—bridging biology, behavior, and a sense of belonging.

Dr Smalls-Mantey is an assistant clinical professor of psychiatry at the NYU Grossman School of Medicine in New York, New York, and was cochair of the nutrition section of the American Psychiatric Association Lifestyle Psychiatry Presidential Workgroup.

Dr Nagarajan is founder and medical director of Joyful Minds Psychiatry in Cary, North Carolina.

Ms Keys is lead physician assistant and vision director at Joyful Minds Psychiatry in Cary, North Carolina, and holds a master’s degree in nutrition.

Dr Merlo is a clinical professor of psychiatry at the NYU Grossman School of Medicine in New York, New York, and was chair of the American Psychiatric Association Lifestyle Psychiatry Presidential Workgroup.

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