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An international task force has published nine new guidelines for using lifestyle-based health care in major depressive disorder, including nutrition. These guidelines, published in this month’s World Journal of Biological Psychiatry, also recognise the importance of input from allied health professionals, including dietitians.

Lifestyle based approaches are already endorsed by the Royal Australian and New Zealand Royal College of Psychiatrists as part of managing depression.

These new guidelines, developed by the World Federation of Societies for Biological Psychiatry (WFSBP) and the Australasian Society of Lifestyle Medicine (ASLM), go beyond physical activity and nutrition to include emerging issues in mental health like tackling loneliness, improving access to green spaces and work-directed interventions.

What do the guidelines recommend?

1. Physical activity and exercise interventions could be used to reduce depressive symptoms in people with Major Depressive Disorder (MDD).
2. Smoking cessation interventions that involve counselling and/or pharmacotherapy (e.g. nicotine replacement) may be used to reduce depressive symptoms in current smokers with MDD.
3. Work-directed interventions A combination of work- focussed counselling and work directed interventions could be used to reduce depressive symptoms in people with MDD.
4. Mindfulness-based therapies (e.g.Mindfulness Based Cognitive Therapy [MBCT] and Mindfulness Based Stress Reduction [MBSR]) could be used to reduce depressive symptoms in people with MDD.
5. Stress management and relaxation techniques (e.g. breathing techniques, progressive muscle relaxation) could be used to reduce depressive symptoms in people with MDD.
6. Dietary counselling to improve nutritional habits that is in line with healthy dietary guidelines and/or nutrient-dense dietary patterns may be used to reduce depressive symptoms in people with MDD.
7. Sleep-related interventions. Cognitive behavioural therapy for insomnia (CBT-I) could be used to reduce depressive symptoms in people with MDD.
8. Improving social support and reducing loneliness may be used to reduce depressive symptoms in people with MDD.
9. Green space interventions Support regarding individualised interaction with green spaces or participation in a green space-focussed program may be used to reduce depressive symptoms in people with MDD.

Dietary interventions and MDD - key points

• There’s consistent evidence of a link between nutrient dense diets and reduced risk of MDD, and several small RCTs with people with MDD have reported moderate to large improvements in symptoms when randomised to a Mediterranean-style diet.  Still, Mediterranean diets aren’t the only answer - the evidence suggests any dietary pattern emphasising nutrient dense, unprocessed foods may help.  
• There’s a lack of clinical trial evidence that more restrictive diets such as the ketogenic or vegan diets are effective.
• MDD and medications to treat it may affect dietary adherence, appetite and food preferences, and other factors like fatigue, reduced motivation and disorganised lifestyles may hamper dietary interventions. Using multimodal techniques, improving awareness of nutrition requirements and providing individuality and structured eating advice may help overcome these challenges.

For more information about the guidelines and the research that underpins them, along with further resources, see 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.   

See also Education in Nutrition Protecting the physical health of people with mental illness presented by Dr Scott Teasdale, APD