Many psychologists will be familiar with the diathesis stress model of mental illness: some people may be predisposed or vulnerable to developing a psychological disorder, but often symptoms only emerge when under stress. Social and environmental stressors may be easily identified, and current treatment programs typically have a focus on symptom reduction. When clients present for therapy, they are often already under stress. Symptom reduction is an important facet of therapeutic care, however, due care and attention to alleviating systemic physiological stress associated with the quality of basic lifestyle can strengthen the foundations of resilience and pave the way to stronger mental health. Lifestyle factors are important to be aware of during case conceptualisation and treatment planning.
A holistic approach to wellbeing endorses the assessment of sleep, nutrition and physical activity, alongside current presentation and symptomatology. Assessing and working with the basic psychophysiological environment of the client can build a solid foundation for change and growth within (and beyond) therapy. A collaborative approach with other appropriate health professionals in the assessment of lifestyle and physiological factors may be necessary for competent and thorough client care in these cases. This article outlines the potential impact of basic lifestyle changes on mental health, quality of life and resilience, with suggestions and implications for clinical practice.
When working with new clients, a brief assessment of nutrition, physical activity, sleep and sunlight exposure may reveal underlying vulnerabilities to poor mental health. Systemic physiological stress and inflammation has an impact on our ability to absorb nutrients from food and thus can impede the construction of neurotransmitters such as dopamine and serotonin. Recent research by Garcia-Toro and colleagues (2012) indicates that advising depressed clients about sleep hygiene, encouraging moderate physical activity, safe sunlight exposure and a healthy and balanced diet, improves mental health outcomes, as compared to pharmaceutical treatment alone.
|BASIC LIFESTYLE STRESSORS FOR MENTAL HEALTH
- Low physical activity
- Intolerance to dietary staples
- Overconsumption of processed or reduced fat foods
- Inadequate sleep
- Vitamin D deficiency from reduced sun exposure
Current Western nutritional guidelines advocate eating a healthy and balanced diet, including a range of fruits and vegetables, meat, grains, fats, legumes and dairy. Access to quality fresh food may be difficult for some clients, and increasingly, research indicates that many people may have underlying food intolerances to gluten, dairy or other common dietary staples. Links have been found between grain consumption and mental health symptoms in psychiatric settings (Kraft & Westman, 2009).
The human body evolved during the Paleolithic era and is optimised to make use of fresh, whole foods. The standard Western diet no longer resembles what our hunter-gatherer ancestors ate, as processed foods are saturated with grains, sugar, food additives and chemicals. Overconsumption of processed and reduced-fat foods may also restrict intake of the healthy and essential fatty acids that are required for optimal cognitive function. The natural variety in diet that was encouraged by a hunter-gatherer lifestyle is no longer supported, as fruits and vegetables are now available year round and out of season. Long distance transportation, processing, refining, freezing and reheating of food results in a loss of nutritional value and decreases our ability to utilise the available nutrients. Today, it is feasible to eat plentifully and remain malnourished or deficient in essential vitamins and minerals. A useful recommendation is to avoid processed food and eat a variety of fresh, seasonal produce. Testing for common food allergies and checking vitamin and mineral levels via blood test can, in some cases, shed light on treatment resistant symptoms and this should be discussed with the client’s GP.
An unidentified dietary intolerance can result in systemic physiological inflammation, having an impact on the ability to absorb and utilise essential vitamins and minerals and impeding construction of neurotransmitters, such as dopamine and serotonin. This may present as lethargy, flat affect, limited concentration, low motivation, gastrointestinal issues and weight gain. In these cases, the introduction of an anti-depressant medication designed to increase the availability of targeted neurotransmitters (such as Selective Serotonin Reuptake Inhibitors; SSRIs) may be ineffective without appropriate nutritional modifications. Collaboration with a medical practitioner or other health professional is the best option to ensure that clients are receiving optimal care for their lifestyle and personal treatment preference.
Alcohol and other substance use has a significant impact on mental health and quality of life. Comorbidity between substance use and mental health issues is well documented; however it is also useful to be aware that any toxic substance entering the body can affect the ability to derive nutrients from food. This can affect concentration, energy levels, motivation, mood and general cognitive function. In mild presentations, a brief discussion or psychoeducational handout regarding the impact of alcohol and other drugs on anxiety, depressive symptoms, mental health and general wellbeing can be an appropriate adjunct to treatment. Health professionals may also be able to provide insight about possible interactions between prescribed medications and alcohol or other substances.
In addition to diet, the level of physical activity has also been affected by modern society. It is no longer necessary to be physically active to ensure survival, and despite government recommendations to engage in at least 30 minutes of physical activity per day, many people do not meet this target. Sedentary lifestyle is a predictor of physical and mental health problems. Regular physical activity has been shown to be as effective as anti-depressant medication in the treatment of mild depression (Mead et al., 2008) and can be useful in ‘resetting’ the fight or flight response when treating anxiety disorders (Herring, O'Connor, & Dishman, 2010).
When prescribing physical activity, it is important to be mindful of the client’s current attitude and physical capacity. Moderate physical activity, such as walking, is achievable for most people and can be paired with mindfulness exercises or other psychotherapeutic interventions. Being ‘time poor’ is a common barrier to physical activity and the pairing of exercise with other tasks can be useful in these cases. In the treatment of anxiety, strenuous bursts of activity may be more effective in flushing excess cortisol and other stress hormones out of the body. Interval training, such as sprints, can be completed in just 10 to 15 minutes per session. Physical strength and mental health are related; as a long-term intervention plan the inclusion of strength training can assist in building stronger foundations for future mental health and wellbeing.
The majority of people with a diagnosed mental illness report sleep disturbance, so fittingly, psychoeducation regarding sleep hygiene is included in the treatment of many mental health issues. Artificial light, abundant screens and constant stimulation can lead to sleep disturbance, and a brief assessment of sleep habits and any history of sleep disturbance may reveal vulnerabilities to strong mental health. Sleep disturbance has an impact on mood, cognitive function, appetite, motivation, digestion and immune system function. If corrected, a foundation of sleep and rest prepares clients to engage in therapy, manage stress and create change.
In practice, assessing sleep habits and discussing healthy approaches to sleep and rest can lay the foundation for psychological therapy. Unaddressed sleep disturbance increases the risk of relapse. Handouts regarding sleep hygiene and healthy sleep routines are readily available online and are useful for clients to take home.
Recently, the impacts of Vitamin D deficiency have been highlighted within the media, and Vitamin D supplements are now widely available in most pharmacies and supermarkets. Even in Australia, a large proportion of people are Vitamin D deficient. Groups at increased risk of Vitamin D deficiency include the elderly, dark skinned people, individuals who are obese, people who work indoors, children and nursing mothers. Low Vitamin D is associated with depression, schizophrenia and postnatal depression. Correcting Vitamin D deficiency promotes the production of dopamine and serotonin and can assist with regular and restful sleep.
Vitamin D deficiency can be followed up by the client’s GP and assessed via blood test. Small amounts of Vitamin D are found in some foods, such as oily fish, eggs and cod liver oil. Safe sunlight exposure is the best way to increase Vitamin D intake and can be prescribed in conjunction with sleep hygiene (such as exposure to natural light in the morning), physical activity and mindfulness exercises. Safe exposure to sunlight involves being exposed to natural sunlight while taking precautions to avoid sunburn or sunstroke. According to the Cancer Council of Australia, during Australian summer regular daily activity and incidental exposure to the sun is adequate for maintaining Vitamin D levels. However, during winter when UV radiation levels are less intense, two to three hours of sunlight to the face, arms and hands, per week, is required. If a client is in one of the high risk categories for Vitamin D deficiency, brief advice for safe sun exposure and the impact of sunlight on mental health can be swiftly and easily provided, with the support of a handout or brochure.
The potential impact of basic lifestyle changes, including attention to nutrition, physical activity, sleep and sunlight exposure, is significant in terms of mental and physical health and wellbeing. These factors are an important part of holistic wellbeing and are relevant to the physical and mental strength of all people. Attention to these factors can create a strong foundation for therapeutic change, relapse prevention, resilience and quality of life.
- Garcia-Toro, M., Roca, M., Monzon, S., Vives, M., Olivan, B., Vicens, E., et al. (2012). Hygienic-dietary recommendations for major depression treatment: Study protocol of a randomized controlled trial. BMC Psychiatry, 12(201). doi:10.1186/1471-244X-12-201
- Herring, M. P., O'Connor, P. J., & Dishman, R. (2010). The effect of exercise training on anxiety symptoms among patients: A systematic review. Archives of Internal Medicine, 170(4), 321-331.
- Kraft, B. D., & Westman, E. C. (2009). Schizophrenia, gluten, and low-carbohydrate, ketogenic diets: a case report and review of the literature. Nutrition and Metabolism, 6(10). doi:10.1186/1743-7075-6-10
- Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. (2008). Exercise for depression. Cochrane Database of Systematic Reviews, 4(CD004366).