Lifestyle Psychiatry for Supporting Individuals With Major Depressive Disorder

SPECIAL REPORT: LIFESTYLE PSYCHIATRY

Major depressive disorder (MDD) is among the leading causes of disability worldwide, affecting approximately 1 in 10 adults annually and rising fastest among adolescents and young adults. It substantially impairs daily functioning, increases risk of cardiovascular disease and premature mortality, and imposes an economic burden exceeding $330 billion each year in the United States.¹ Despite widespread use of pharmacotherapy and psychotherapy, many patients experience residual symptoms, adverse effects, and relapses, while prevalence continues to climb.

Lifestyle psychiatry offers an evidence-based, low-risk, and cost-effective third pillar of care alongside psychotherapy and medication. It encompasses interventions such as nutrition, physical activity, sleep, social connection, nature exposure, and substance use reduction, which together target modifiable drivers of poor mental health and physical comorbidity. Recent clinical guidelines from the World Federation of Societies for Biological Psychiatry, the Lancet Psychiatry Commission, and the Royal Australian and New Zealand College of Psychiatrists emphasize that lifestyle modification should be a foundational component of depression treatment.^2-4 By addressing both mental and physical health and improving overall well-being, lifestyle psychiatry expands the focus of care beyond symptom relief to holistic recovery and resilience.

For all the target lifestyle behaviors recommended by the guidelines, effectiveness will be maximized when delivered in conjunction with behavior change techniques that are appropriate for the person and their circumstances and when supported by input from relevant allied health professionals (eg, dietitian, exercise physiologist) and engaging support networks (including in the community) in the delivery of the interventions.²

This article synthesizes recent research, practice points, and a clinical case across 7 key domains of lifestyle psychiatry:

• Nutrition
• Physical activity and movement
• Stress management and mind-body approaches
• Sleep health
• Social connection
• Nature connection
• Substance use reduction

The Figure shows how lifestyle strategies can be integrated within a stepped care model that allocates treatment according to clinical severity and complexity. This model underscores that lifestyle modification is a core component of treatment at every level of severity rather than an optional adjunct.

Nutrition: Food and Mood

Evidence base

A 2020 meta-review of lifestyle psychiatry demonstrated that dietary patterns that focus on highly nutritious whole foods have been associated with a reduced risk of depression, whereas diets high in ultraprocessed foods are associated with an increased risk.⁵ Multiple randomized controlled trials (RCTs) have now demonstrated that dietary interventions, particularly a Mediterranean-style diet, can significantly reduce depressive symptoms in those with depression.⁶ For example, the SMILES trial found that 32% of participants with moderate to severe depression achieved remission on a dietary program, compared with only 8% in the control group.⁶ A meta-analysis of RCTs of over 45,000 participants showed that dietary improvement reduces depression and anxiety symptoms, with stronger effects in women.⁷

Proposed mechanisms include, but are not limited to, reductions in inflammation and oxidative stress, improved gut microbiome composition, and improved mitochondrial function.⁸

Practical guidance

• Screen for dietary patterns in practice.
• Encourage adherence to nutrient-dense, minimally processed dietary patterns, such as the Mediterranean diet, and recommend incremental changes (eg, add 2-3 servings of vegetables daily).
• Incorporate joy, social connection, and mindfulness into the “food experience” where possible.
• Dietary advice and prescription should be individualized with specific consideration of ethical, spiritual and/or religious preferences, comorbidities, food intolerances and allergies, taste preferences, and socioeconomic status.
• Collaborate with dietitians where available.

Physical Activity and Movement

Evidence base

Physical activity has medium to large effect sizes for reducing depressive symptoms, comparable to psychotherapy and pharmacotherapy. All physical activity modes are effective, and higher-intensity exercise is associated with greater improvements in depression and anxiety.⁹ Furthermore, a large meta-analysis of cohort studies of over 40,000 individuals showed that physical activity lowers the risk of future psychotropic medication use by 15%.¹⁰ Both aerobic and resistance training are effective, with additional evidence for yoga.¹¹ Mentally passive sedentary behavior (such as watching devices) itself is an independent risk factor for MDD, and prolonged sitting may blunt exercise benefits (ie, “exercise resistance”).¹²

Safe and appropriate physical activity is beneficial for neurobiological, psychosocial, and behavioral processes in the body, including increasing brain-derived neurotrophic factor and growth hormone, reducing inflammation, stimulating the prefrontal cortex and hippocampus, and improving self-efficacy and social support.¹³

Practical guidance

• Inquire about and encourage individuals to engage in modes of physical activity that they enjoy and at a frequency and intensity that they can sustain.
• Prescribe any movement as a starting point; build intensity gradually.
• Target World Health Organization guidelines (150-300 minutes per week of moderate physical activity with a combination of aerobic and resistance/strength forms), but emphasize sustainability.
• Encourage enjoyable and socially embedded activities (walking groups, dance classes, team sports).
• Supervised programs (with exercise physiologists) improve adherence and safety.

Sleep Health

Evidence base

Sleep disturbance is a well-established risk factor for depression across the lifespan and has been hypothesized to play a role in both the onset and persistence of depressive symptoms.¹⁴ Sleep disturbances are highly prevalent in individuals with MDD, correlating with MDD severity, and are independently associated with suicidal ideation and suicide attempts.⁵ In RCTs of participants with mental health problems, nonpharmacological sleep interventions, including cognitive behavioral therapy for insomnia (CBT-I) and stimulus control therapy, had a large positive effect, reducing the severity of depression symptoms.

Practical guidance

• Routinely assess sleep hygiene (bedtime consistency, light exposure, caffeine and alcohol intake).
• Offer CBT-I where indicated; brief versions (4-6 sessions) are effective.
• Treat sleep comorbidities (sleep apnea, restless legs).
• Monitor for interactions between hypnotics, antidepressants, and circadian rhythms.

Social Connection

Evidence base

The impact of trusted social connections is causally protective for depression, with the ability to “confide in others” being identified in large studies as the single strongest protective factor against MDD.¹⁵ Large cohort studies show that perceived social isolation predicts both the onset and persistence of depressive symptoms, while strong social support is among the most protective factors against MDD. Trusted relationships buffer stress, enhance coping, and improve treatment outcomes. Conversely, social disconnection is linked to greater severity, relapse, and poorer physical health. While social media can help maintain contact, excessive or compulsive use (eg, high-frequency use in combination with a variety of addiction symptoms, such as dependence, tolerance, and withdrawal [eg, use on first waking, prioritizing over other needs]) is associated with higher depressive symptoms, highlighting the need for balanced digital engagement.

Practical guidance

• Assess social networks, social media use, perceived support, and barriers to social engagement.
• Encourage structured group interventions and social prescribing (peer groups, volunteering, interests).
• Use behavior change techniques to support reconnecting with past and present beneficial social connections that have become dormant and establishing new social connections through shared values and interests.
• Interventions should be personalized to individual circumstances and preferences (eg, religiosity, spirituality) and may incorporate other lifestyle domains (eg, team sport).

Stress Management and Mind-Body Approaches

Evidence base

Mind-body approaches in people with MDD can take various forms, including mindfulness, meditation, relaxation therapies, breathing techniques, and visualization. Results of RCTs show that mindfulness-based cognitive therapy (MBCT) is both clinically effective and cost-effective for relapse prevention and symptom reduction in depression compared with CBT.¹⁶ Meta-analyses of RCTs show relaxation therapies, including breathing techniques, autogenic training, and progressive muscle relaxation, can effectively reduce depressive symptoms among adults with depression, are cost-effective and safe, and can be easily taught and used, with particular benefits if continued for 8 or more weeks.¹⁷

Practical guidance

• Identify and address the underlying sources of stress, if possible.
• Identify sources of resilience and current coping strategies.
• Offer guided relaxation or MBCT in primary and secondary care, in both chronic illness and acute distress (when appropriate).
• Encourage regular practices (10-20 minutes per day), highlighting greater benefits with consistent practice.

Nature Connection

Evidence base

Nature prescriptions are gaining popularity as a form of social prescribing in support of sustainable health care. Nature prescriptions have a moderate to large effect on depression and anxiety scores. The most common activities recommended to participants were walking in nature, farming or gardening, and relaxation activities such as meditation or breathing exercises in nature settings, among a range of other activities (art and craft, group sports, reading or listening to music, etc).¹⁸

Practical guidance

• Encourage daily outdoor activity in green or blue spaces.
• Prescribe “nature doses” (eg, 30 minutes in a park, 3 times per week).
• Integrate into structured interventions such as “green gyms” or horticultural therapy.
• Seek out formal programs, such as walking groups, garden tours, and outdoor mindfulness and exercise programs, where available.

Substance Use Reduction

Evidence base

Contrary to popular belief, smoking and alcohol cessation improve, not worsen, mental health. A Cochrane review showed that smoking cessation is associated with reductions in depressive and anxiety symptoms.¹⁹ An added benefit to smoking cessation is the impact on cytochrome P450 enzymes 1A2 and 2B6, which are induced by cigarette smoking. These enzymes metabolize several clinically important drugs, including clozapine, olanzapine, and methadone; hence, smoking cessation may mean potential dose reductions.²⁰ Similarly, alcohol reduction improves quality of life and depressive symptoms.²¹

Practical guidance

• Screen for tobacco, alcohol, and drug use at every consultation.
• Emphasize evidence that cessation improves mental health.
• Offer pharmacological aids (eg, varenicline, naltrexone) alongside behavioral support.
• Collaborate with addiction services when needed.

Clinical Case

“Mark,” a 42-year-old unemployed man, is diagnosed with severe MDD characterized by pervasive low mood, anhedonia, and marked fatigue. His fatigue had initially been attributed solely to his mental illness, leading to a cycle of inactivity and social withdrawal. A structured lifestyle assessment, however, identified an untreated sleep disorder. Following targeted treatment for the sleep condition, Mark experienced substantial improvements in alertness and energy.

This new capacity enabled Mark to engage in a progressively loaded physical activity program, starting with brief daily walks and progressing to structured exercise. As his fitness improved, so too did his self-efficacy, motivation, and social interaction skills. These gains created momentum for further lifestyle change: He reported an intrinsic desire to improve his nutrition, adopting healthier eating patterns, and subsequently committed to smoking cessation with clinician support.

The cumulative impact of these changes extended beyond symptom reduction. Mark reported improved self-worth, social confidence, and functional recovery. Over time, these gains enabled him to pursue training as a peer support worker. He is now employed in this role, where his lived experience and recovery journey allow him to support others facing similar challenges. This case illustrates how addressing foundational behaviors can unlock engagement in treatment and foster functional recovery.

Implementation Challenges

Despite a growing and robust evidence base, lifestyle interventions remain markedly underutilized in the management of MDD. Common barriers exist at multiple levels: Clinicians often receive limited training in lifestyle psychiatry; service models remain heavily weighted toward acute pharmacological care; and structural issues such as time constraints, funding limitations, and poor access to allied health persist. At the patient level, low motivation, socioeconomic disadvantage, and stigma present further challenges. The recent Lancet Psychiatry Commission highlights that these barriers are not isolated but systemic, reflecting an entrenched evidence-implementation gap across mental health services worldwide.³ Importantly, enabling factors have also been identified, including interprofessional collaboration, behavior change support, and the use of qualified allied health professionals, which significantly improve intervention fidelity and outcomes. Embedding programs within routine care pathways, tailoring interventions to cultural contexts, and involving peer workers or those with lived experience further enhance engagement and equity. Together, these insights underscore the need for psychiatrists and mental health teams to move beyond acknowledging the evidence and actively redesign service delivery to ensure lifestyle psychiatry is embedded as core clinical practice rather than an optional adjunct.

Concluding Thoughts

Lifestyle psychiatry remains underutilized despite its evidence base and transformative potential for people with MDD. Nutrition, movement, stress management, sleep, social and nature connection, and substance reduction are powerful levers to improve outcomes, reduce relapse, and address the physical health disparities that drive premature mortality. Psychiatrists are uniquely placed to champion these interventions, working collaboratively with allied health professionals and embedding lifestyle approaches as a core component of treatment plans. By moving beyond symptom suppression toward holistic recovery, lifestyle psychiatry offers hope for transforming care in major depression, supporting not only remission but also resilience, well-being, and long-term health by addressing lifestyle and social determinants—the roots of whole-person care.

Dr Manger is the academic lead and senior lecturer of the postgraduate suite in lifestyle medicine at James Cook University College of Medicine and Dentistry, as well as the former president of the Australasian Society of Lifestyle Medicine.

Dr Marx is a senior research fellow and deputy director of Deakin University Food & Mood Centre. He is also president of the International Society for Nutritional Psychiatry Research.

References

1. Greenberg P, Chitnis A, Louie D, et al. The economic burden of adults with major depressive disorder in the United States (2019). Adv Ther. 2023;40(10):4460-4479.

2. 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.

3. Teasdale SB, Machaczek KK, Marx W, et al; Lancet Psychiatry Physical Health Commission Consortium. Implementing lifestyle interventions in mental health care: third report of the Lancet Psychiatry Physical Health Commission. Lancet Psychiatry. 2025;12(9):700-722.

4. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49(12):1087-1206.

5. Firth J, Solmi M, Wootton RE, et al. A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry. 2020;19(3):360-380.

6. Bizzozero-Peroni B, Martínez-Vizcaíno V, Fernández-Rodríguez R, et al. The impact of the Mediterranean diet on alleviating depressive symptoms in adults: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev. 2025;83(1):29-39.

7. Firth J, Marx W, Dash S, et al. The effects of dietary improvement on symptoms of depression and anxiety: a meta-analysis of randomized controlled trials. Psychosom Med. 2019;81(3):265-280.

8. Marx W, Lane M, Hockey M, et al. Diet and depression: exploring the biological mechanisms of action. Mol Psychiatry. 2021;26(1):134-150.

9. Singh B, Olds T, Curtis R, et al. Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. Br J Sports Med. 2023;57(18):1203-1209.

10. Wolf S, Meinzinger E, Frei AK, et al. Is higher physical activity behaviour associated with less subsequent use of any psychotropic medication: results of a random-effects meta-analysis of prospective cohort studies. Ment Health Phys Act. 2024;27:100645.

11. Wu Y, Yan D, Yang J. Effectiveness of yoga for major depressive disorder: a systematic review and meta-analysis. Front Psychiatry. 2023;14:1138205.

12. Huang Y, Li L, Gan Y, et al. Sedentary behaviors and risk of depression: a meta-analysis of prospective studies. Transl Psychiatry. 2020;10(1):26.

13. Vancampfort D, Firth J, Stubbs B, et al. The efficacy, mechanisms and implementation of physical activity as an adjunctive treatment in mental disorders: a meta-review of outcomes, neurobiology and key determinants. World Psychiatry. 2025;24(2):227-239.

14. Gee B, Orchard F, Clarke E, et al. The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials. Sleep Med Rev. 2019;43:118-128.

15. Choi KW, Stein MB, Nishimi KM, et al. An exposure-wide and Mendelian randomization approach to identifying modifiable factors for the prevention of depression. Am J Psychiatry. 2020;177(10):944-954.

16. Strauss C, Bibby-Jones AM, Jones F, et al. Clinical effectiveness and cost-effectiveness of supported mindfulness-based cognitive therapy self-help compared with supported cognitive behavioral therapy self-help for adults experiencing depression: the Low-Intensity Guided Help Through Mindfulness (LIGHTMind) randomized clinical trial. JAMA Psychiatry. 2023;80(5):415-424.

17. Li M, Wang L, Jiang M, et al. Relaxation techniques for depressive disorders in adults: a systematic review and meta-analysis of randomised controlled trials. Int J Psychiatry Clin Pract. 2020;24(3):219-226.

18. Nguyen PY, Astell-Burt T, Rahimi-Ardabili H, et al. Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review. Lancet Planet Health. 2023;7(4):e313-e328.

19. Taylor GM, Lindson N, Farley A, et al. Smoking cessation for improving mental health. Cochrane Database Syst Rev. 2021;3(3):CD013522.

20. Lucas C, Martin J. Smoking and drug interactions. Aust Prescr. 2013;36:102-104.

21. Charlet K, Heinz A. Harm reduction—a systematic review on effects of alcohol reduction on physical and mental symptoms. Addict Biol. 2017;22(5):1119-1159.