First Published in September 2018 Issue of Kai Tiaki (NZ Nurses Organisation Journal), with edits.

According to the Mental Health Foundation, “one in six New Zealand adults have been diagnosed with a common mental disorder at some time in their lives (including depression, bipolar disorder and/or anxiety disorder)”. (1) The percentage of 15 to 24-year-olds in New Zealand struggling with what is considered high or very high psychological distress has been steadily increasing, affecting five per cent of this population five years ago, 8.8 per cent in 2015/2016 and 11.8 per cent in 2017. (2) This trend is expected to continue, according to the World Health Organization, with “depression set to become the second leading cause of disability in the world by 2020”. (3) The rates of suicide in New Zealand are also continuously increasing, with 668 for 2017/2018, the highest number recorded since 2007/2008. (4)

As a nurse who previously worked in mental health, these statistics are alarming. Recently, there have been studies which looked at lifestyle measures which may assist recovery from some mental illness. This article looks briefly at the research, primarily on anxiety and depression, and what we, as nurses, need to be aware of to help our patients and perhaps our loved ones, to recover.

In 2017, a promising Australian study was published, aptly titled the SMILES study.5 Put simply, the purpose was to seek to answer the question: “If I improve my diet, will my mental health improve?” It was a 12-week, parallel-group single blind, randomised controlled dietary intervention trial in the treatment of moderate to severe depression. Sixty-seven people who were suffering from depression were divided into two groups. The intervention group was given a modified Mediterranean diet. The results suggested that “dietary improvement may provide an efficacious and accessible treatment strategy for the management of this highly prevalent mental disorder”.5 In fact, remission, ie absence of depression, was achieved for 32.3 per cent of the participants in the intervention group. (5)

Specific micronutrients have also been studied in more detail. In New Zealand, clinical psychologist Julia Rucklidge, who works at Canterbury University, has been studying the results of micronutrients on mental illness. (6) Although she looks at supplementation rather than simple dietary changes, the research results are compelling. (6) Other researchers have examined the data on nutrients, including Omega 3 fatty acids, antioxidants (vitamin C and zinc), members of the vitamin B family (vitamin B12 and folic acid) and magnesium, in depression, post-traumatic stress disorder and suicide. The results suggested these nutrients could enhance neurocognitive function, and may have therapeutic benefits for depression and suicidal behaviours. (7) The authors concluded there was an “intriguing possibility that regular consumption of these nutrients may help prevent the onset of mood disorders and suicidal behaviours in vulnerable individuals, or significantly augment the therapeutic effect of available antidepressants.” (7)

When one looks at how neurotransmitters are produced in the body, it is easy to see the relationship between amino acid intake (from protein), micronutrients (such as zinc and magnesium) and neurotransmitter production. Many of the above nutrients, eg zinc, magnesium and B6, play an important role in the conversion of amino acids to neurotransmitters which affect our mood. (See Table 1, below.)

For example, amino acids such as tyrosine and tryptophan require folic acid, B6, magnesium and zinc to transform into the neurotransmitters serotonin and dopamine.

Exploring the recent discoveries on the microbiome and gut health, a systematic review looked at the effects of probiotics on depressive symptoms. (7) It suggested “the evidence for probiotics alleviating depressive symptoms is compelling . . .” (8) Probiotics can be naturally consumed in fermented foods such as sauerkraut, yogurt or miso, or taken as a supplement. Although the evidence is still lacking as to whether specific probiotics can have an impact on mood, a recent study done by the University of Auckland suggested that pregnant women taking Lactobacillus rhamnosus HN001 had significantly lower depression and anxiety scores up to six months after giving birth, than those in the placebo group. (9)

Diet and nutrition, however, are only two aspects of recovery. Mental health requires a multidimensional approach. Exercise, good sleep and socialisation are also helpful. In the Cochrane review, Exercise for depression, the authors concluded: “Exercise seems to improve depressive symptoms in people with a diagnosis of depression when compared with no treatment or control intervention.” (10) Being outside and exposed to sunshine can also be useful. A study of people suffering from multiple sclerosis showed that greater exposure to sunshine may decrease depressive symptoms, despite no correlation to vitamin D levels. (11)

Insomnia predicted a two-fold increased risk for a depressive episode. (12) Sleep is often problematic for people with mental illness, although it is difficult to know what comes first, the illness or the insomnia. Supporting good sleep hygiene may provide some benefit. In a meta-analysis of mindfulness based therapies, these therapies were found to be moderately effective for improving anxiety and mood symptoms. (13)

Aspects of mindfulness are also supported by the Mental Health Foundation, which uses the term Take Notice as one of the five ways to well-being. (14)

As a mental health nurse for more than 15 years, I find the evidence of these studies compelling. How can we give our mental health clients the best chance of recovery when it comes to diet and lifestyle choices? From the research, a number of factors may assist recovery:

• A modified Mediterranean-type diet.

• Ensuring micronutrient intake is maintained, either through diet or supplements.

• Supporting sleep hygiene.

• Exercise.

• Safe sun exposure.

• Encouraging mindfulness-based practices.

There are many other lifestyle changes which have been shown to support recovery, such as socialisation, pet therapy, having a sense of purpose, avoiding alcohol and other substances of abuse, all of which may contribute to the health and well-being of those we work with. The research is available about what supports mental health and well-being, and all of the above can be used in conjunction with standard treatments for depression. As advocates for our clients, we can enhance recovery by educating, supporting and calling for a wider focus when it comes to healing from a mental illness, alongside the traditional medical model approaches of medication and talk therapy.

1) Mental Health Foundation. (2015). Quick Facts and Stats 2014. Retrieved from www.mentalhealth.org.nz/assets/Uploads/MHF-Quick-facts-and-stats-FINAL-pdf

2) Ministry of Health. 2018. Health and Independence Report 2017: The Director-General of Health’s Annual Report on the State of Public Health. Wellington: Ministry of Health.

3) World Health Organization, 2001. Mental Heath – A Call for Action by World Health Ministers. Retrieved from www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf

4) Office of the Chief Coroner of New Zealand.(August 24, 2018). Chief Coronor releases provisional annual suicide figures. Retrieved from coronialservices.justice.govt.nz/assets/Documents/Publications/20180824-Provisional-suicide-statistics-2017-18-media-release.pdf

5) Jacka, F. N., O’Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., …Berk, M. (2017). A randomised controlled trial of dietary improvement for adultswith major depression (the “SMILES” trial). BMC Medicine, 15, 23.doi.org/10.1186/s12916-017-0791-y

6) Rucklidge, J. (2014). TEDx Talks: The surprisingly dramatic role of nutrition in mental health. Retrived from www.youtube.com/watch?v=3dqXHHCc5lA

7) Du, J., Zhu, M., Bao, H., Li, B., Dong, Y., Xiao, C., … Vitiello, B. (2016). The Role of Nutrients in Protecting Mitochondrial Function and Neurotransmitter

Signaling: Implications for the Treatment of Depression, PTSD, and Suicidal Behaviors. Critical Reviews in Food Science and Nutrition, 56(15), 2560–2578. doi.org/10.1080/10408398.2013.876960

8) Wallace, C. J. K., & Milev, R. (2017). The effects of probiotics on depressive symptoms in humans: a systematic review. Annals of General Psychiatry, 16, 4.doi.org/10.1186/s12991-017-0138-2

9) Slykerman, R. F., Hood, F., Wickens, K., Thompson, J. M. D., Barthow, C., Murphy, R., … the Probiotic in Pregnancy Study Group. (2017). Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial. EBioMedicine, 24, 159–165.doi.org/10.1016/j.ebiom.2017.09.013

10) Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., McMurdo, M., Mead G. E. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. doi:1002/14651858.CD004366.pub6.

11) Knippenberg, S., Damoiseaux, J., Bol, Y.,Hupperts, R., Taylor, B. V., Ponsonby, A.L., Dwyer, T., Simpson, S., van der MeiI, A. F. (2013) Higher levels of reported sun exposure, and not vitamin D status, are associated with less depressive symptoms and fatigue in multiple sclerosis (Abstract)

12) García-Toro, M., Ibarra, O., Gili M., Serrano, M. J., Oliván, B., Vicens, E., & Roca M. (2012). Four hygienic-dietary recommendations as add-on treatment indepression: a randomized-controlled trial. Journal of Affective Disorders, 140(2), 200-203.

13) Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review. Journal of Consulting and Clinical Psychology, 78(2), 169–183. doi.org/10.1037/a0018555

14) Mental Health Foundation of New Zealand. (2018). The Five Ways to Wellbeing. Retrieved from www.mentalhealth.org.nz