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By Grant H. Brenner
We know that lifestyle changes are key to ensuring long-term health and well-being, positively impacting mental and physical health and the synergy between them when included in a comprehensive, individualized treatment plan. It can be hard to separate the signal from the noise when it comes to focusing time and energy on lifestyle-based changes given the explosion of variably-reliable information on the web.
Assessing the Evidence for Lifestyle Investment
Researchers Marx et al., in The World Journal of Biological Psychiatry (2023), compiled the relevant literature on lifestyle and MDD. They reviewed thousands of articles and grading the evidence into Strong (“Should”), Limited (“Could”), Low (“May”) and No evidence. Eight core lifestyle factors associated with potential MDD relief were identified. Notably, none had a “Strong” evidence-base, making “Limited” best-in-class.
Source: Marx et al., 2023, Open Access
1. Physical activity and exercise interventions (Limited)
Depression is associated with reduced levels of activity, and increasing movement and exercise may be of benefit. The mechanisms are unclear, but include potentially increasing BDNF (brain-derived neurotrophic factor), increasing neural plasticity, stress reduction/resilience; reduced inflammation, stimulating different brain areas; and improved psychosocial factors (see below).
Source: Marx et al., 2023, Open Access
2. Smoking cessation interventions (Low)
Smoking reduces the risk of many health problems, notably cardiovascular and pulmonary health, diabetes and early death, markedly self-destructive. While studies suggest that reducing or stopping smoking may relief depressive symptoms, limited evidence shows that stopping smoking definitively improves MDD. Stopping smoking now will secure better future overall health.
Source: Marx et al., 2023, Open Access
3. Work-directed interventions (Limited)
Counseling via the workplace and other interventions (wellness programs, resilience trainings, etc.), could offer relief to people with clinical depression. Work-related psychoeducational programs and burnout-prevention can contribute to alleviating or preventing depression. Such interventions may also improve work performance, increasing productivity and reducing days missed. Reducing mental health stigma, building effective work-based programs, and removing barriers to mental healthcare are among best practices.
Source: Marx et al., 2023, Open Access
4. Mindfulness-based and stress management interventions (Limited)
Approaches including Mindfulness-based Cognitive Behavioral Therapy (MB-CBT) and Mindfulness-Based Stress Reduction (MBSR) could be helpful. Stress management and relaxation techniques, including breathing practice and progressive muscle relaxation, also may reduce depressive symptoms when used properly1.
Source: Marx et al., 2023, Open Access
5. Dietary interventions (Low)
Surprisingly, given the amount of media buzz and intuitive appeal, the evidence for dietary changes preventing or alleviating clinical depression is of low quality. There is more evidence, as with smoking cessation, that diet and nutrition impact physical health, which would be expected to improve mental health indirectly (e.g. by increasing sense of self-efficacy, enabling exercise, etc.). True nutritional deficiencies may cause depression-like syndromes, and dietary modification may contribute to reduced inflammation and stress-reactions, improving brain health, possibly alleviating depression2.
Source: Marx et al., 2023, Open Access
6. Sleep-related interventions (Limited)
There is a relatively strong association with improving sleep and reducing or preventing clinical depression. Insomnia is a core symptom of depression, and poor sleep worsens baseline mood and irritability. Sleep deficit also impairs cognitive function. These factors in turn drive problems in personal and professional function, leading to a vicious cycle. Interventions which improve sleep, such as CBT-I (Cognitive Behavioral Therapy for Insomnia), are associated with improved depression. Treating depression likewise improves sleep quality. Depression and insomnia feed off of each other.
Source: Marx et al., 2023, Open Access
7. Loneliness and social support-related interventions (Low)
Depression includes social withdrawal and low self-esteem as core symptoms, impacting the ability to secure social support. Loss of social support and loneliness likewise can precipitate depression and are associated with negative impact on physical well-being. Perceived social support is a core factor for resilience, as well. Nevertheless, research has not robustly looked at whether interventions targeting social support and loneliness are effective with clinical depression.
Depression Essential Reads
Source: Marx et al., 2023, Open Access
8. Green space interventions (Low)
The evidence for green space interventions, like nature therapy, gardening or spending time in green urban spaces, does not show a substantial causal relationship. Studies have not looked in detail at whether the type of green space matters, and factors such as pollution and noise in urban spaces may offset benefits. In addition, increased physical activity and exercise is a key factor in green space interventions, with a stronger evidence base. Structured green space interventions often increase social support, making it harder to tease apart effects.
Making Effective Lifestyle Choices
At the end of the day, given the lack of strong evidence for any of the above interventions, individualized lifestyle programming is needed, combined with proper treatment and clinical judgment, to determine what will be most effective for a given individual. Do what makes you feel good and is healthful, and consult with appropriate professionals as needed.
Given the state of the art, an open, experimental approach is likely to yield the best results, with trials of different interventions designed to find out what works best for a given person at a given time. It’s advisable to focus on interventions with a stronger base, and follow recommendations based on available evidence: physical activity and exercise, work-related interventions, mindfulness-based and stress management, and sleep-related interventions have the best available evidence.
Study authors offer guidelines:
- Delivery of lifestyle lifestyle-based mental health care is suggested to be in line with our proposed conceptual framework
- Explore individual factors (e.g. financial, geographical, medical and social considerations) when initiating behaviour change to promote uptake and sustainability
- Explore the individual’s capability, opportunity, and motivation for initiating and maintaining behaviour change
- Encourage the individual to seek out formal programs relevant to lifestyle interventions that provide supervision and structured activity.
- Encourage the individual to incorporate social components (e.g. clubs, community groups, friends and/or family) to interventions.
- Clinicians are encouraged to engage with relevant allied health professionals and specialists, where warranted
- Consider the integration of digital and online tools to lifestyle interventions to assist with adherence and self-management