The Clinical Uses and Importance of Lifestyle Medicine in Psychiatry

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From The Clinic: The Art of Psychiatry, we focus on lifestyle medicine. Lifestyle modifications have gone from being thought of as adjuncts to disease management to pillars of treatment. The core is proper habit formation and ultimately, the hope of disease-modifying practices in everyday life. Lifestyle medicine has evolved into a subspecialty with 88 core competencies. Lifestyle modifications bridge the gap between thoughtful self-care, stress management, and risk avoidance. Links to inflammation, microbiome effects, and neuroplasticity continue to be uncovered.

Case Study

“Raven” is a 25 year old woman referred to a psychiatrist by her mother because of concerns of depression. When taking Raven’s social history, Raven reports that she often feels no motivation to get out of bed, and she experiences difficulty going to sleep and staying asleep. She regularly sleeps for approximately 4 hours every night. She rarely leaves the house, save for taking a smoke break. She believes that her only reprieve from anxiety is smoking, but shortly thereafter, even stronger feelings of uneasiness plague her, throwing her into worse anxiety, insomnia, and bouts of depressive mood. She rarely joins the family for dinner. Instead, her diet mainly consists of easy and accessible fast foods. She reports feelings of social isolation, and does not have any friends. Raven has considered joining a community gym, but she sees no point at the moment. Her mother has tried to encourage her to take daily walks with her, but Raven does not believe there is much benefit to that either. She does not believe she has depression and does not really want professional mental health treatment.

What Is Lifestyle Medicine?

Lifestyle choices are a significant contributor to potential disease development in adult life. Furthermore, once disease has developed, lifestyle factors are potent contributors to trajectories of these diseases. Smoking tobacco, sedentary lifestyle, and poor diet all contribute to chronic noncommunicable diseases that are the most prevalent in the global adult population.¹ With chronic diseases on the rise, sustained behavior change is the most effective way to manage these preventable conditions.

Lifestyle medicine places a strong emphasis on prevention of disease over curative medicine. By integrating lifestyle medicine into patient care, chronic preventable diseases can be modified or potentially reversed, if caught early and aggressively combatted.² General principles of lifestyle medicine center on understanding health behavior change theories, such as the health belief model, the social learning theory, and the transtheoretical model of change. These models can serve as a basis for the patient visit and future treatment planning. The efficacy of lifestyle medicine is the focus of studies for metabolic syndrome, heart disease, and more. Reductions of coronary stenosis in patients with coronary heart disease from treatment with lifestyle medicine in the form of diet modification, exercise, smoking cessation, and counseling were noted even in absence of medications, highlighting the promise of lifestyle modifications for coronary artery disease.³ In the setting of metabolic syndrome remission rates, habit formation to sustain lifestyle medicine interventions showed effectiveness: after 6 months of intervention with lifestyle medicine habit formation, 25% of the participants sustained remission for the next 18 months.⁴ The habit formation intervention and actual practice was done specifically in groups so that peer support and positive peer pressure could encourage motivation among participants.

The pillars of lifestyle medicine, according to the American College of Lifestyle Medicine, are nutrition, physical activity, stress management, sleep, social connection, and avoiding dangerous substances (Figure).⁵ It has been long understood that there is a connection between certain psychiatric disorders and lifestyle decisions. Mortality for individuals with severe mental illness (SMI) remains higher than that for those without, and individuals with SMI die of noncommunicable diseases, highlighting the potential impact of lifestyle choices for individuals with mental illness. By encouraging behavioral changes through lifestyle medicine’s idea of prevention, psychiatrists and mental health clinicians can explore its effectiveness on patients’ mental health.

As lifestyle medicine’s popularity grows for physical health, its efficacy for mental health requires further investigation. The core of lifestyle medicine efficacy is proper habit formation, which can impact anhedonia, negative symptoms, and others. Firmly established habits can also help mitigate bipolar disorder fluctuations. There are no guidelines for lifestyle medicine implementation in mental illnesses, but the World Federation of Societies for Biological Psychiatry and Australasian Society of Lifestyle Medicine taskforce did issue 9 recommendations in 2023 summarizing current evidence of lifestyle modifications for major depressive disorder. Recommendations for physical activity and exercise, relaxation techniques, work-directed interventions, sleep, and mindfulness-based therapies are based on evidence. Interventions related to diet and green space are recommended but have lower evidence based on the current literature state. Those regarding smoking cessation and loneliness and social support are based on expert opinion.

Smoking

Smoking is the leading cause of preventable deaths globally and is a major risk factor for preventable, noncommunicable diseases.⁶ When comparing groups that continued smoking with groups that quit smoking, smoking cessation groups experienced a higher quality of psychological life with less anxiety, depression, and stress.⁶ Smoking was found to be associated with depression, and though a causal link is not certain, it was found that individuals who smoke were significantly more likely to develop depression when compared with their counterparts who did not smoke.⁷ Therefore, when it comes to the pillar of lifestyle medicine that encourages stopping or avoiding dangerous behavior to improve quality of life, smoking cessation is a crucial step.

Diet

The link between diet and disease has been well researched and widely accepted. However, diet is not generally considered the first line of action when treating one's psychological quality of life. High adherence to a Mediterranean diet was shown to correlate with a lower incidence of depression.⁸ In contrast, a western inflammatory diet was observed with a higher incidence of depression. Although this needs to be further studied, several explanations have been proposed. One such explanation is that certain inflammatory foods contribute to systemic inflammation, thereby affecting neurotransmitters such as dopamine, serotonin, and glutamate.⁸ Dietary patterns adjust key processes that share common etiologies with mood disorders.⁹ Numerous studies have established that there is an association between healthy eating patterns and lower incidences of depression, therefore supporting the value of lifestyle medicine’s nutrition regulation component. Microbiome changes are linked to mood changes and this is the likely path of lifestyle effect on mood; at this point, microbiome studies and lifestyle medicine studies still do not overlap and much work is needed in this field.

Exercise

Studies over the years have confirmed that physical activity, mostly aerobic, is an essential part of preventative and curative maintenance of health. Physical activity is beneficial to patients who suffer from mental health issues on various levels. Physical activity has been credited for protecting against the development of depression, and physical inactivity has been established as a risk factor for developing depression.¹⁰ Proposed hypotheses to explain this connection are that physical activity serves as a distraction from negative stimuli and the ability to partake in challenging physical activity increases positive self perception.^10,11 Furthermore, there can be an inherent social connection in group physical activity.¹⁰ It is hypothesized that physical activity increases neuroplasticity which is crucial for successful treatment outcomes.¹¹ As disease-modifying as the exercise pillar of lifestyle medicine appears, it should be prescribed with thorough education to avoid over-exertion and excessive dependence on physical activity in the case of individuals who are prone to addictive behaviors.¹²

Social Connectedness

Social isolation and lack of community are known to be detrimental to health. This is especially true for adults over the age of 50, as stated by the Centers for Disease Control and Prevention.¹³ During the COVID-19 outbreak, social isolation was required to control disease spread and led to negative effects, ranging from feelings of loneliness to worsening depression. More than one-third of adolescents and more than half of 18 to 24 year olds reported experiencing significant loneliness during the 2020 lockdown.¹⁴ Loneliness was found to have a strong correlation with social anxiety, eating disorders, and most notably, depressive symptoms. Children who experienced significant social isolation were found to require mental health service intervention five times more often than those who did not.¹⁴ Those with a negative sense of community were found to report higher levels of anxiety, stress, and depression.¹³ Therefore, social support and community is a necessity to combat the health detriment of isolation and loneliness. In the case example, social isolation is serving as both a perpetuating factor for depression and a symptom for Raven.

Sleep

Sleep and its associations with mental health has been greatly researched. Sleep problems are common in individuals with mental disorders such as anxiety, bipolar disorder, and depression. Sleep disorders are more commonly known to precede depression, and insomnia makes treatment outcomes for depression much worse.¹⁵ Sleep quality and quantity are both significant in depressive symptoms. Insomnia has a very high association with depression. This is substantiated in many studies for adults and adolescents. Sleep deprivation can increase the risk of depressive symptoms by 4- to 5-fold.¹⁶ National surveys highlight the relationship with depressive symptoms and too much sleep or poor quality of sleep.¹⁷ Treatment of depression without treatment of insomnia, for example, can lead to a greater risk of relapse of depression.¹⁵ Therefore, the importance of sleep that is highlighted by lifestyle medicine is significant for successful treatment of mental illness.

Concluding Thoughts

Lifestyle medicine emphasizes the importance of preventative measures before curative medicine is needed. The pillars of lifestyle medicine—including avoidance of dangerous behavior, a balanced diet, social support, physical activity, and healthy sleep patterns—are all highlighted to ensure positive treatment outcomes. Preventative medicine can decrease the risk of chronic noncommunicable diseases that ail adults globally. These same pillars, when addressed, can assist the treatment and decrease the risk of certain mental illnesses, most notably anxiety and depression. All of the pillars of lifestyle medicine play a key role in supportive treatment for mental illness. However, reversal of mental illness by any 1 pillar is not easily achievable and needs further study.

Furthermore, although there is evidence and hypotheses as to how each pillar affects mental health, there needs to be further research to determine the exact relationship between each pillar and its effects on one's psychological quality of life. Ultimately, lifestyle medicine can play a supportive role in the treatment and prevention of mental illness by mitigating its risk factors and may influence symptom development and treatment.

Ms Abbas is a medical student at the University of the Incarnate Word School of Osteopathic Medicine.

Dr Shah is Professor & Executive Vice Chair Barbara & Corbin Robertson Jr. Chair in Psychiatry, Menninger Department of Psychiatry & Behavioral Sciences, and Chief of Psychiatry at Ben Taub Hospital.

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