Issues in Lifestyle Psychiatry: November Special Report Recap

Nature Nurtures: Evidence for Nature’s Impact on Mental Well-Being

Jeremy D. Wortzel, MPhil; Ianna Hondros-McCarthy, DO; Sarah Kovan, MD, MSc; and Cynthia Peng, MD

A Breath of Air

In spring 2002, Jonathan Dosick was hospitalized at an inpatient psychiatric facility in Massachusetts. The days could feel long, and the unit, like so many, was often “sterile and boring.” What made a difference were the small freedoms: stepping outside for a walk or sitting down with a hot chocolate at the local coffee shop. “I really appreciated that,” he recalls, “because it helped me feel connected to the world outside. The cold, fresh air can be bracing. Going outside can help you reconnect with what’s out there; it is a bridge back to the outside world.”¹ Not long after his discharge, Jonathan learned that the hospital had stopped letting patients go outside at all, citing concerns about elopement. Having just experienced firsthand how vital those moments of fresh air could be, he thought to himself, "That’s not right." This marked the beginning of his work as a peer advocate and a wider conversation about the essential role of nature in psychiatric care.

From Intuition to Evidence

Across cultures and throughout history, people have turned to nature for comfort, healing, and perspective. Only recently, however, researchers have begun to quantify just how powerful time in green space can be for supporting mental health, showing links to lower stress, improved mood, and even reduced psychiatric symptoms. These benefits appear to arise through multiple pathways: reducing exposure to pollutants, encouraging healthier and prosocial routines, and buffering the stress response. It is therefore imperative to explore the science and stories that illustrate these effects and to address the challenges of ensuring equitable access to outdoor spaces. Recommendations should therefore weave nature into mental health care—from lifestyle choices to clinical augmentation of established treatment practices to the development of supportive national policies.

Hippocrates, the proverbial father of medicine, is widely credited with the saying that “nature itself is the best physician,” reflecting his belief in the environment’s capacity to heal.² Enlightenment thinkers retreated to gardens and forests seeking tranquility, whereas early 20th-century sanitariums prescribed fresh air and open landscapes as treatment for tuberculosis. For centuries, humans have intuitively turned to the natural world for restoration. What distinguishes the present moment is the mounting body of scientific evidence validating that intuition. Advances in epidemiology, neuroscience, and experimental design allow us to examine how access to green space influences mental health.

Green space is defined broadly, which has historically limited consistent understanding across disciplines and geographic regions.³ It can include public parks, gardens, tree-lined streets, natural views from windows, and even indoor plants. Although green space dominates the literature, it is important to recognize that blue spaces, such as rivers, lakes, and seascapes, are also associated with improved well-being. ⁴

Over the past 35 years, research examining green space and mental well-being has expanded rapidly. A 2020 bibliometric analysis showed that the number of observational and experimental studies increased sharply after 2000, reflecting the field’s growing recognition.⁵ A later 2024 review in Nature synthesized 41 studies focusing on the impact of green space on the mental health of disadvantaged populations. Of those studies, 70% found that neighborhood green space exerted a protective effect on mental health, with outcomes including greater life satisfaction, reduced depression, and improved emotional well-being—even when controlling for socioeconomic status.⁶ These findings are particularly significant because access to green space has historically been shaped by racist and classist policies such as redlining, underscoring that equitable access is both a mental health and an environmental justice issue.⁷ The COVID-19 pandemic offered an unfortunate natural experiment that further reinforced these inequities. During periods of lockdown, individuals with higher amounts of green space in their zip codes reported lower rates of depression, anxiety, and COVID-19–specific worries compared with those with less access to green space.⁸ This stark contrast underscored how access to nature is not merely a lifestyle preference but a determinant of mental health resilience during times of crisis.

In addition to general mental well-being, green space has an association with the development of specific psychiatric disorders. One of the most compelling studies comes from Denmark, where researchers tracked nearly 1 million individuals born between 1985 and 2003, quantifying green space exposure around their childhood homes. In a dose-dependent relationship, lower levels of green space in childhood were associated with a 15% to 55% increased risk of developing psychiatric disorders later in life (including mood, schizophrenia spectrum, and substance use disorders), even after adjusting for urbanicity, socioeconomic status, and family psychiatric history.⁹ This suggests that green space exposure during early development may be important for mental health across our lifetimes.

Of course, much of this evidence is observational. To establish causality, randomized controlled trials are essential, and here, too, the data are compelling. In Philadelphia, Pennsylvania, Eugenia C. South, MD, MSHP, and colleagues randomly assigned more than 500 vacant lots into several treatment groups, including a greening intervention that involved removing trash, grading the land, and planting grass and trees, vs a control group with no intervention at all. Residents living near fully greened lots reported significant decreases in feelings of depression and worthlessness compared with controls.¹⁰ These results demonstrate not only that green space promotes mental health, but also that urban greening interventions are feasible, scalable, and capable of addressing mental health disparities in urban communities.

How Nature Heals

Why does green space matter for mental health? Researchers have proposed 3 broad mechanisms: harm mitigation, encouragement of healthy behaviors, and psychological restoration.¹¹

In terms of harm mitigation, green space buffers exposure to air pollution, noise, and heat—all of which disproportionately affect vulnerable groups and can impact cognitive development.¹¹ With respect to healthy behaviors, natural settings encourage physical activity and social interaction, providing both physical benefits and social coping strategies. Finally, psychological restoration may be the most direct mechanism by which green space impacts mental health (though it remains an active area of study). Studies suggest that exposure to natural environments impacts brain circuits involved in attention restoration, stress reduction, and rumination.¹² For example, one experiment found that individuals who took a 90-minute walk in nature showed decreased activation in the subgenual prefrontal cortex, a region associated with maladaptive rumination, whereas those who walked in urban settings did not.¹³

At the same time, the absence of green space—or the presence of urban stressors—appears to shape neural development in measurable ways. Functional neuroimaging studies of individuals with urban upbringings show heightened amygdala activity during stress and altered connectivity in the anterior cingulate cortex, both of which are critical regulators of the limbic stress response.¹⁴ These findings reinforce that exposure to natural vs urban environments may leave lasting imprints on brain structures tied to emotional regulation, but more studies are needed to unpack these effects.

Beyond these established mechanisms, researchers are beginning to uncover additional ways the natural world may influence mental health. For example, emerging research shows that spending time in nature can alter the gut microbiome in ways that meaningfully affect mental well-being.¹⁵ Even exposure to bird sounds has been shown to exert protective effects on anxiety and paranoia.¹⁶ These findings highlight how much there is still to learn about the subtle but powerful ways nature supports our mental health.

Taken together, the evidence is striking. From Hippocrates’ early observations to modern neuroimaging, the data converge on a central truth: Nature matters for mental health. Green space access is not merely an aesthetic or recreational amenity but can be a meaningful determinant of psychiatric well-being.

Translating Evidence Into Practice

The growing body of evidence demonstrating the positive relationship between nature and mental health has already started to influence the health care system. Mental health professionals and hospitals have started to integrate green space therapeutics into care. These interventions should be framed as additions to our therapeutic tool kit: powerful but complementary to the established practices of psychotherapy and psychopharmacology.

At its most basic, green exposure therapy involves getting people outdoors, often through group walks in natural settings. A 2023 review of 16 studies found that such walks improved mood, optimism, and overall well-being, with significantly greater benefits in natural vs urban environments.¹⁷ Horticultural therapy, which uses gardening and plant-based activities as a therapeutic medium, also has a large body of evidence. A 2022 meta-analysis of 18 randomized controlled trials demonstrated significant reductions in general measures of mental health.¹⁸ Finally, Shinrin-yoku, or forest bathing, a Japanese practice of mindful immersion in nature, has been associated with improvements in mood disorders. Early randomized controlled trials provide positive evidence supporting its role as an adjuvant to psychotropic medication.¹⁹ Taken together, these emerging approaches highlight the diverse ways nature-based interventions can augment traditional psychiatric care.

In the outpatient clinical setting, some clinicians are weaving these practices into routine care. One widely adopted strategy is the nature prescription, a nonpharmacological recommendation that directs patients to spend time in parks or other natural settings. Rooted in the tradition of nonmedical prescriptions for exercise, nature prescriptions extend this model to environmental exposures, encouraging restorative time outdoors. More than 100 park prescription programs now exist across the United States, supported by organizations such as the National ParkRx Initiative and Park Rx America.²⁰ Grassroots programs like Walk With a Doc take this concept further, facilitating physician-patient walks in community parks.²¹ Although formal evidence for these initiatives is limited, and more studies are needed to assess the impacts, anecdotal experiences highlight the restorative value of fresh air, movement, and social connection.

The availability of fresh air and natural environments has been shown to be just as crucial to patient mental health inside the hospital as it is outside the hospital. Started by the wonderful work of Dosick, in Massachusetts, a bill was drafted and sponsored by former state representative Denise Provost and Senator Patricia Jehlen to add “daily access to fresh air and the outdoors” to the preexisting fundamental rights in the Massachusetts Department of Mental Health licensing codes (adding to access to phones, mail, visitors, privacy and dignity, and legal counsel). It was initially filed in 2005 and, after 5 legislative sessions, finally passed a decade later on Governor Deval Patrick’s last day in office in 2015.²²

As advocacy for the implementation of this policy continues, hospital systems are developing creative solutions for biophilic design and incorporating natural environments into inpatient behavioral health settings, such as through nature art.^23,24 One initiative is underway at Brigham and Women’s Faulkner Hospital in Boston, Massachusetts. After construction blocked patient views of nearby trees and green space, a team, led by Christopher AhnAllen, PhD; Sarah Kovan, MD; and Jeremy Wortzel, MD, partnered with the Osher Center for Integrative Medicine to install immersive nature photography throughout the psychiatric unit (Figure). Vinyl installations of tree canopies, lakes, and forest scenes replaced blank white walls, and the team is now studying the impact of these interventions on patient well-being. This project highlights a broader movement: When outdoor access is limited, bringing nature indoors can still provide meaningful therapeutic benefit.

Yet despite this growing body of evidence, challenges remain. Access to green space is still deeply unequal across communities, with marginalized groups often facing the greatest barriers. In inpatient psychiatric units, concerns about safety, staffing, and resources frequently limit opportunities to go outdoors.²⁵ Creating safe therapeutic spaces requires funding not only for infrastructure but also for adequate staffing to ensure patient well-being. Although some local legislation has begun to address outdoor access in psychiatric settings, we still lack effective, nationally standardized, and enforceable policies that guarantee safe, equitable green space access for all patients.

Recommendations for Clinical Practice

Moving forward, several recommendations can help bridge this gap. These strategies should be understood as augmentation tools—creative ways of broadening psychiatric care while always remaining grounded in our core evidence-based practices of psychotherapy and psychopharmacology. At the lifestyle level, clinicians can encourage patients to spend time outdoors and to incorporate restorative natural experiences into daily routines. In outpatient care, nature prescriptions, outdoor therapy groups, and walking groups may help patients engage with the mental health benefits of green space. For inpatient settings, dedicating more resources toward outdoor time or integrating nature into the unit through artwork and indoor greenery can begin to transform sterile units into more therapeutic environments. On a broader scale, advocacy for national legislation is crucial to ensure green space becomes a standardized, enforced, safe, and well-resourced component of psychiatric care, guaranteeing that every person, regardless of where they live or are treated, has access to the healing power of nature. Integrating nature into mental health care represents an emerging frontier—one grounded in both empirical evidence and the moral pursuit of holistic healing.

Dr Wortzel is a chief resident at Mass General Brigham – Brigham and Women’s Hospital/Harvard Medical School. Dr Hondros-McCarthy is a child, adolescent and adult psychiatrist in an integrated behavioral health position within a pediatric practice through Tufts Medical Center. Dr Kovan is a chief psychiatry resident at Brigham and Women’s Hospital/Harvard Medical School. Dr Peng is currently an inpatient psychiatrist at McLean Hospital.

References

1. Hondros-McCarthy I. The fresh air break law: how it came to be, and how well is it being implemented? J Am Acad Child Adolesc Psychiatry. 2024;63(10):S28-29.

2. Lloyd GER. Hippocratic Writings. Penguin Random House; 1984.

3. Taylor L, Hochuli DF. Defining greenspace: multiple uses across multiple disciplines. Landsc Urban Plan. 2017;158:25-38.

4. Vitale V, Martin L, White MP, et al. Mechanisms underlying childhood exposure to blue spaces and adult subjective well-being: an 18-country analysis. J Environ Psychol. 2022;84:101876.

5. Collins RM, Spake R, Brown KA, et al. A systematic map of research exploring the effect of greenspace on mental health. Landsc Urban Plan. 2020;201:103823.

6. Xian Z, Nakaya T, Liu K, et al. The effects of neighbourhood green spaces on mental health of disadvantaged groups: a systematic review. Humanit Soc Sci Commun. 2024;11(1):488.

7. Nardone A, Rudolph KE, Morello-Frosch R, Casey JA. Redlines and greenspace: the relationship between historical redlining and 2010 greenspace across the United States. Environ Health Perspect. 2021;129(1):17006.

8. Wortzel JD, Wiebe DJ, DiDomenico GE, et al. Association between urban greenspace and mental wellbeing during the COVID-19 pandemic in a US cohort. Front Sustain Cities. 2021;3:686159.

9. Engemann K, Pedersen CB, Arge L, et al. Residential green space in childhood is associated with lower risk of psychiatric disorders from adolescence into adulthood. Proc Natl Acad Sci U S A. 2019;116(11):5188-5193.

10. South EC, Hohl BC, Kondo MC, et al. Effect of greening vacant land on mental health of community-dwelling adults: a cluster randomized trial. JAMA Netw Open. 2018;1(3):e180298.

11. Zhang R, Zhang CQ, Rhodes RE. The pathways linking objectively-measured greenspace exposure and mental health: a systematic review of observational studies. Environ Res. 2021;198:111233.

12. Kaplan Y, Levounis P. Nature Therapy. American Psychiatric Association Publishing; 2024.

13. Bratman GN, Hamilton JP, Hahn KS, Daily GC, Gross JJ. Nature experience reduces rumination and subgenual prefrontal cortex activation. Proc Natl Acad Sci U S A. 2015;112(28):8567-8572.

14. Lederbogen F, Kirsch P, Haddad L, et al. City living and urban upbringing affect neural social stress processing in humans. Nature. 2011;474(7352):498-501.

15. Sobko T, Liang S, Cheng WHG, Tun HM. Impact of outdoor nature-related activities on gut microbiota, fecal serotonin, and perceived stress in preschool children: the Play&Grow randomized controlled trial. Sci Rep. 2020;10(1):21993.

16. Stobbe E, Sundermann J, Ascone L, Kühn S. Birdsongs alleviate anxiety and paranoia in healthy participants. Sci Rep. 2022;12(1):16414.

17. Ma J, Lin P, Williams J. Effectiveness of nature-based walking interventions in improving mental health in adults: a systematic review. Curr Psychol. 2024;43(11):9521-9539.

18. Tu H. Effect of horticultural therapy on mental health: a meta‐analysis of randomized controlled trials. J Psychiatr Ment Health Nurs. 2022;29(4):603-615.

19. Kotera Y, Richardson M, Sheffield D. Effects of Shinrin-yoku (forest bathing) and nature therapy on mental health: a systematic review and meta-analysis. Int J Ment Health Addict. 2022;20(1):337-361.

20. James JJ, Christiana RW, Battista RA. A historical and critical analysis of park prescriptions. J Leis Res. 2019;50(4):311-329.

21. Sabgir D, Dorn J. Walk with a Doc—a call to action for physician-led walking programs. Curr Cardiol Rep. 2020;22(7):44.

22. Licensing and Operational Standards for Mental Health Facilities. Massachusetts Department of Mental Health. 2021.

23. Huntsman DD, Bulaj G. Healthy dwelling: design of biophilic interior environments fostering self-care practices for people living with migraines, chronic pain, and depression. Int J Environ Res Public Health. 2022;19(4):2248.

24. Nanda U, Eisen S, Zadeh RS, Owen D. Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case. J Psychiatr Ment Health Nurs. 2011;18(5):386-393.

25. Slemon A, Dhari S. When should inpatient psychiatric care include access to the outdoors, despite elopement or other risks? AMA J Ethics. 2024;26(3):E212-E218.

Religion and Spirituality in Psychiatry and Mental Health: Clinical Considerations

Victor Pereira-Sanchez, MD, PhD

Care for individuals with severe mental illness was historically largely institutionalized in faith-based settings. Yet, modern psychiatry ("medicine of the soul") often viewed religion and spirituality (R/S) with skepticism and even hostility, which corresponded with the suspiciousness of modern psychiatry within religions.¹ Although a loss of public faith has challenged both religion and psychiatry, we are seeing a growing realization of their mutually enriching relationship, and research is increasingly showing strong and consistent positive effects of R/S beliefs and practice in overall mental well-being and in particular mental health conditions.^2,3

Although psychiatrists, especially in the United States, have traditionally been particularly secular, they need to care for the large proportion of patients for whom R/S is important and handle their mental health and engagement with care.^4,5 The World Psychiatric Association and the American Psychiatric Association have recognized the crucial role of R/S and the need to incorporate those dimensions in psychiatric training and patient care.^6,7 Religious communities are increasingly attuned to the mental health needs of their members and open to collaborations with professionals. Definitely, the field of interaction between R/S, psychiatry, and mental health is ripe for impactful research and innovation in the care for patients and communities, or, using words from Jesus Christ in the Bible, "white for harvest" (John 4:35).

This article aims to provide clinicians with an overview of how R/S often intersect with the mental health of their patients, informing and improving their assessment and care. Although there is a growing proportion of people identifying as spiritual but not religious, R/S substantially overlap in theory and are often indistinguishably blended in the lives of most individuals. Given this reality, this article will follow the approach of research and literature on the topic, which often deals with R/S together, noting instances of practical distinction.^2,8,9

Case Vignettes

The following fictional vignettes illustrate the role of R/S in the psychopathology, coping, and management of individuals from diverse religious and spiritual backgrounds in the US.

Vignette 1: Ms Perez

“Ms Perez” is a 26-year-old South American Catholic woman who recently immigrated with her toddler. She struggles with traumatic memories, sadness, and scrupulosity, and she has a precarious financial situation. Some of her first experiences with older members at her new parish made her feel unwelcome and stigmatized, yet she finds relief in talking frequently to the priest. The priest notices an unhealthy obsessive pattern and the history of trauma and encourages her to check in with the parish mental health ministry. The ministry offers her the opportunity to join a spiritual support group for immigrant women at the parish and connects her with professional counseling, delivered by a community lay provider at the parish offices, as well as with an external psychiatrist for specialized assessment and care. Alongside those services, she continues to receive regular spiritual direction and confession from the priest. She participates in the social and worship activities of the parish's young adult group, where she feels accepted, forgiven, supported, and loved by God and the community.

Vignette 2: Mr Elmi

“Mr Elmi” is a 38-year-old Muslim man born to immigrants from the Middle East who had fled a very violent war. Since his early twenties, he has struggled with severe mood swings. Although his condition has had a significant impact on his academic and professional performance and often damaged his marriage, he has never received care due to the reluctance of his family to publicly expose his situation and their lack of trust in Western psychiatry. His parents have also attributed his afflictions to the influence of evil spirits that are punishing their son for abandoning their country of origin. After his condition can no longer be hidden from their wider religious community in their neighborhood, a Muslim psychiatrist and an Imam offer to collaborate in his care, integrating mental health care for his finally diagnosed bipolar disorder with faith-based accompaniment in prayer and understanding of his religious heritage and the impact of trauma on his parents. His marked improvement after these interventions are in place is appreciated by his family, who progressively gain an understanding of the problem, develop more supportive attitudes, and feel at peace, finally relieved from the evil spirits.

Vignette 3: Ms Cohen

“Ms Cohen” is a 75-year-old, widowed, and retired Jewish American woman. Since her young adult years, she has not been particularly religious or spiritual, yet she has fondly endorsed the core ethical values instilled in her by her parents. She has been struggling with complex, prolonged grief since the death of her husband, with whom she had been married for more than 3 decades. After she started interpersonal therapy, marked improvements in her daily functioning led to her being motivated to dedicate the last stage of her life to flourishing. She has found how other widows endure their grief with the support of faith and spiritual and transcendental meaning and practices. She is eager to revisit some of the traditions from her parents and her youth and considers incorporating other practices from other traditions, such as yoga, mindfulness, and meditation, in an eclectic fashion. She asks her therapist whether those might mingle well with therapy and help her further gain peace and flourishing in her grief, as well as a healing connection with her deceased husband.

Vignette 4: Mr Harris

“Mr Harris” is a 49-year-old African American Baptist Christian man who is divorced. Since a young age, he has suffered from recurrent depression and alcohol use disorder, which started after the death of his mother and worsened after an accident that left him in chronic pain. He has never consistently engaged in psychotherapy, motivational interviewing, or pharmacological treatment due to his sense of a lack of rapport with providers and a health care system insensitive to his sociocultural background and racial experiences. His increased financial instability and alcohol dependence, alongside his loss of faith and religious practice, have brought him to a point of intense and concrete suicidal ideation. When he discloses his despair while getting a haircut, his barber, who is trained in the recognition of mental health signs through a community-partnering local program, encourages him to seek help at a Black church. Though initially skeptical, he progressively finds himself at home among his peers. He engages with and benefits from counseling at the church-affiliated clinic, joins the church's 12-step group, resumes Sunday worship, and becomes a peer advocate and counselor. Although still with chronic pain and frequent cravings for alcohol, he is at peace in the conviction that Jesus saves him and has spared his life to be a witness to the healing of faith and a supporter of peers who are in despair.

As reflected in the vignettes above, R/S offers, for many individuals, resources for meaning, community, and integrative mental health care for the whole person. R/S has the potential to blend well with professional mental health care and promote long-term healing. Community-based resources and partnerships help promote access to culturally sensitive care, especially for underserved populations, including ethnic minority and migrant groups. The following sections of the article will describe the scientific and conceptual bases, as well as the practical applications, for psychiatrists and mental health professionals to better care for their patients, many of whom embody stories similar to those illustrated in the vignettes.

Research, Practice, Conceptual Models, and Challenges

A growing body of research, which includes large longitudinal cohorts examining outcomes for individuals who report varying degrees of importance given to R/S and actual participation, has shown consistent and strong positive effects on life satisfaction, general physical health, and certain mental health conditions.^9,10 Solid protective effects have been demonstrated in depression, suicidality, and substance use, with more mixed or inconclusive indications for anxiety, obsessive-compulsive disorders, psychosis, and other disorders; there is some evidence for possible limited or negative effects in specific populations.^3,9 Positive effects have been seen for the specific dimension of frequent participation in religious worship, to the point that it has been suggested that there is a causal relationship, and that approximately 40% of the increased incidence in suicide in the US between 1999 and 2014 could be attributed to a decline in religious attendance.¹⁰ In addition, spiritual practices from Eastern religious traditions, such as yoga and mindfulness, which are nowadays common secularized practices in the West, have shown health benefits and are integrated in some evidence-based therapies.⁹ Growing implementation research is exploring the feasibility and potential of collaborations between the mental health sector and faith-based organizations to support, in particular, underserved communities.¹¹

Less is known about the mechanisms of these effects. Some of the biggest challenges in religion, spirituality, and health research are the theoretical difficulty and perhaps practical impossibility of discerning the "active ingredients" (more likely, patterns) that drive the effects and their mechanisms of action. The question also remains whether the mental health benefits of R/S can be obtained through removing or bypassing faith and institutional foundations of certain practices, such as in secular and New Age syncretic meditation, artificial intelligence, technology, or psychedelics.¹² In general, positive effects are driven by the strong and enduring grounding and coping power of R/S's core values (such as compassion and forgiveness), the healthy lifestyles and respect for one’s life that those promote, and the social support and compassion of faith-based communities. Negative effects stem from sometimes seen aspects such as scrupulosity, intolerant hatred, and individualism, along with stigma and discrimination within communities, all of which are often misrepresentations of religions.¹³

From a biopsychosocial lens, the field of neurotheology is emerging as the study of the brain correlates with R/S values and practices, while acknowledging highly complex intraindividual and interpersonal human dimensions.¹⁴ R/S intersect with general and physical health in multiple and synergistic effects through the biopsychosocial model, to the point that an integrative biopsychosocial-spiritual paradigm would see spirituality not as a dimension that is parallel and overlapping with the others, but rather permeating and integrating them all.¹⁵ A deeper understanding of such interactions requires a dive into philosophy and theology, with integrative models such as the Catholic Christian Meta-Model of the Person that confront the reductionisms of the dualistic, materialistic paradigms in secular neuroscience and psychiatry.¹⁶

In the realm of routine clinical practice of mental health professionals and in public health, all of the cited research and explanatory or conceptual models translate to the fact that R/S often present as part of the psychopathology or coping and supportive resources of patients. Patients’ R/S beliefs and practices often influence their explanations of disease, their attitudes toward treatment, and their help-seeking behaviors, representing opportunities for more comprehensive clinical assessments and holistic, sustainable treatment interventions.

Recommendations for Clinical Assessment and Interventions

Given patients’ needs and opportunities of R/S in their mental health, clinicians are called to routinely incorporate R/S into assessments and interventions in an environment of cultural humility, and to foster collaborations with faith-based organizations and leaders through frameworks such as Community Outreach and Professional Engagement (COPE) to further support patients and communities.¹⁷

The DSM-5-TR Cultural Formulation Interview (CFI), with its supplementary module Spirituality, Religion, and Moral Traditions, includes guidance for an exploration of the patient's spiritual, religious, and moral identity and the role of those in the patient's life and mental health issues, noting their potential as coping resources and as sources of stress and conflict.¹³ Apart from assessment, CFI can support treatment by helping build culturally sensitive rapport and engagement with patients and identifying aspects of the R/S lives of patients that might cultivate beneficial aspects and address the negative.

Lifestyle psychiatry focuses on habits and behaviors that strongly positively or negatively affect mental and overall health. It empowers patients to take the lead in their recovery and health maintenance journeys through their daily actions beyond clinician-provided treatments. The model supported by the APA includes R/S within connectedness, 1 of the 6 pillars of lifestyle psychiatry.^18,19 Although the dimensions of lifestyle are interconnected, R/S especially intersect connectedness and all lifestyle pillars, as, for instance, major traditions emphasize temperance in eating and occasional fasting, cultivation of interior peace, a balanced life of activity and rest, and avoidance of harmful substances.¹⁸ Lifestyle psychiatry can also be a valuable practical framework for informing assessment and treatment and for engaging patients in the integration of their faith, values, and practices into the cultivation of physically and mentally healthy habits (Table).

Concluding Thoughts

The often seen as parallel and conflicting realms of religion, spirituality, psychiatry, and mental health are recently converging due to mutual need and in light of robust research on their strong and generally beneficial associations. R/S practices and communities are showing as valuable assets for patients and promising avenues for their clinicians to better understand and serve them. Clinicians will benefit from learning with research and explanatory and practical frameworks; they should incorporate universal and as-needed R/S assessments and interventions into their practices.

R/S, psychiatry, and mental health can and should better understand one another. We should partner to synergize them to respond to the global syndemic crisis of mental health and other threats to human health, societies, and ecology, with both empirical evidence and supernatural hope.

Dr Pereira-Sanchez is a child, adolescent, and adult psychiatrist from Spain, and a New Yorker since 2019. He is dedicated to local and global mental health, with leading involvement in pioneering and award-winning efforts to improve mental health, especially for underserved populations. He’s currently a global mental health and implementation science research fellow at Columbia University, where he is coleading multilateral partnerships between mental health, academic, government, and nonprofit sectors with local Catholic churches in underserved Hispanic neighborhoods in New York, New York, including his parish.

Acknowledgements

The author thanks his colleague and friend, Djibril Moussa, for his clinical insights and feedback in the conception and crafting of the case vignettes. The author is also very grateful to the National Institutes of Health, Columbia University, and Milton Wainberg and Connie Svob for their support for his current postdoctoral research training. A final word of thanks to religious leaders and communities that support the mental health of their members all over the world, and in particular, the colleagues at the Church of St Elizabeth and the International Association of Catholic Mental Health Ministers.

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15. Saad M, de Medeiros R, Mosini AC. Are we ready for a true biopsychosocial–spiritual model? the many meanings of “spiritual.” Medicines (Basel). 2017;4(4):79.

16. Vitz PC, Nordling WJ, Titus CS, eds. A Catholic Christian Meta-Model of the Person: Integration with Psychology and Mental Health Practice. Divine Mercy University Press; 2020.

17. Milstein G, Currier JM, Dent C, et al. COPE: Community Outreach & Professional Engagement – a framework to bridge public mental health services with religious organizations. Front Psychiatry. 2025;16:1461804.

18. Merlo G, Porter-Stransky KA, Sugden SG, et al. American Psychiatric Association Lifestyle Psychiatry Presidential Workgroup Report. Am J Psychiatry. 2025;182(9):885-887.

19. Merlo G, Pereira-Sanchez V, Lee W, et al. Connectedness as a mental health pillar: to self, others, and the world. Psychiatric Annals. 2025;55(7):e164-e169.

20. Lucchetti G, Bassi RM, Lucchetti AL. Taking spiritual history in clinical practice: a systematic review of instruments. Explore (NY). 2013;9(3):159-170.

Continuing Conversations in Lifestyle Psychiatry

Gia Merlo, MD, MBA, MEd

We are fortunate to be members of a dynamic field of medicine, constantly evolving our understanding of the etiology of symptoms with new evidence-based data. To this end, I suggest that the evidence on the role of lifestyle in preventing, managing, and sometimes reversing not only physical disease but also mental suffering, is compelling. What exciting times to be able to weave together another approach and add to our toolbox of available interventions for our patients.

In this Special Report, we present articles that reflect the broad discipline of lifestyle psychiatry, which encompasses 6 pillars: (1) physical activity and exercise; (2) healthy nutrition; (3) restorative sleep; (4) minimizing the effects of toxic exposures (substances and environment); (5) stress management; and (6) connectedness.¹ These pillars are an expansion and adaptation of the needs of our patients from the field of lifestyle medicine. Although lifestyle medicine stresses that up to 50% of chronic diseases (eg, type 2 diabetes, cardiovascular disease, etc) can often be prevented, treated, and even reversed with lifestyle interventions, lifestyle psychiatry suggests that our patients with depression, psychosis, mania, and cognitive health issues can also be markedly affected by lifestyle.^2,3 Partnering with our patients to implement these behaviors may help them reduce their dose of medication, minimize the metabolic consequences of long-term use, and bidirectionally improve physical ailments.

The importance of lifestyle interventions for health is not a new concept. It is clear to most of us that exercising regularly, eating nutritious food, managing stress, having restorative sleep, minimizing unhealthy substance use, and maintaining positive connectedness to oneself, others, and society constitute a path to well-being. What is new is the availability of evidence to support our adopting these approaches with our patients.

In 2023, the World Federation of Societies for Biological Psychiatry (WFSBP) partnered with the Australasian Society of Lifestyle Medicine Task Force to publish clinical guidelines for the use of lifestyle-based care in major depressive disorder (MDD).⁴ These guidelines were published in the World Journal of Biological Psychiatry, which is not a lifestyle journal, indicating significant movement toward increasing awareness for data in this burgeoning field. The guidelines concluded that “lifestyle-based interventions are recommended as a foundational component of mental health care in clinical practice for adults with [MDD].”

While giving lectures on this topic to primary care physicians (who often treat half of the patients with depression), clinicians' understanding of how lifestyle could help treat mental illness is limited. I found that psychiatrists were hungry for information and data to benefit their patients. The WFSBP may have put out guidelines, but how many of us have read them? To that end, the American College of Lifestyle Medicine partnered with multiple experts in psychiatry, primary care, and cardiology to develop an expert consensus statement (ECS) on the use of lifestyle interventions in MDD. Through a Delphi method, the group reached a consensus on 71 statements. This ECS is pending publication in early 2026 and hopefully will inform psychiatrists and primary care physicians on the topic. As the field of lifestyle psychiatry evolves and gains wide dissemination of knowledge, 2 textbooks on lifestyle psychiatry and hundreds of peer-reviewed papers are available to guide us.

Our Special Report on lifestyle psychiatry also aligns with the theme of the 2025 American Psychiatric Association Annual Meeting—Lifestyle for Positive Mental and Physical Health—where more than 150 of the general sessions included lifestyle themes.

The Special Report is presented in 2 parts—December 2025 and January 2026. In this issue, we include articles that explore religion and spirituality, green spaces, and lifestyle changes for MDD. Connectedness is foundational to lifestyle psychiatry; it is a construct that includes a connection to ourselves, our community, and the social world at large. Indeed, although much is written about the importance of social connection, I believe there is more to the health of humans vis-à-vis connection.⁵ Our connection to ourselves includes our ability to empathize, show compassion—to self and others—and our relationship to the self. For many of us, healthy aspects of this self-connectedness are necessary to optimize our life journey and allow us the joy of connections with others and society. Data have shown that having a purpose and meaning in life can be protective for our mental health.⁵ Our connectedness to the community includes addressing aspects of social connection and building support and peer relationships meaningful for the individual. Finally, our relationship with religion, spirituality, and nature can be protective lifestyle aspects of connectedness to the world at large. In this issue, we further the conversation around lifestyle psychiatry with a selection of topics useful to our practice.

Dr Merlo is a clinical professor of psychiatry at New York University Grossman School of Medicine and a distinguished fellow of the American Psychiatric Association.

References

1. Merlo G, Porter-Stransky KA, Sugden SG, et al. American Psychiatric Association lifestyle psychiatry presidential workgroup report. Am J Psychiatry. 2025;182(9):885-887.

2. Katz DL, Frates EP, Bonnet JP, et al. Lifestyle as medicine: the case for a true health initiative. Am J Health Promot. 2018;32(6):1452-1458.

3. Merlo G, Vela A. Mental health in lifestyle medicine: a call to action. Am J Lifestyle Med. 2021;16(1):7-20.

4. Marx W, Manger SH, Blencowe M, et al. Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce. World J Biol Psychiatry. 2023;24(5):333-386.

5. Merlo G, Snellman L, Sugden SG. Connectedness: the updated and expanded pillar of lifestyle psychiatry and lifestyle medicine. Am J Lifestyle Med. 2025:15598276251345455.