Lifestyle-based mental health care in psychiatry: Translating evidence into practice

Introduction

There is a large and growing body of evidence that supports the efficacy and cost-effectiveness of lifestyle-based mental health care, targeting physical activity, diet, smoking and sleep, in the prevention and management of mental disorders. The new paradigm for understanding the relevance of lifestyle in both the aetiology and treatment of mood disorders is considered somewhat revolutionary in mental health and expands our traditional understanding of primary risk factors such as genetic, early life, socioeconomic and personality factors. The evidence is now such that lifestyle behaviours are given serious recognition as modifiable prevention and treatment targets. This is concomitant with the increasing focus on mitigating the substantial mortality gap arising from the cardiometabolic conditions so prevalent in people living with mental disorders (Firth et al., 2019b). Given the burden of mental disorders and limitations of existing approaches to prevention and treatment in mental health care, we urgently need to bridge the evidence–practice gap to bring lifestyle-based mental health care to people living with mental illness. The recent 2020 Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for mood disorders represents a significant milestone in this process (Malhi et al., 2021). These guidelines recommend that dietary, exercise and sleep improvement, alongside smoking, alcohol and other substance use cessation, should form the foundation of mood disorder management, describing it as ‘essentially non-negotiable’ (Malhi et al., 2021). Here, we discuss the future directions needed to translate and firmly embed lifestyle-based mental health care into practice.

What do the guidelines say?

The recent 2020 RANZCP clinical practice guidelines for mood disorders contain recommendations, resources and advice for psychiatrists, psychologists and General Practitioners providing mental health care for mood disorders (unipolar and bipolar depression) (Malhi et al., 2021). Based on evidence grading, the authors recommend lifestyle targets form part of the ‘Action’ phase of the treatment of mood disorders (Malhi et al., 2021). This includes instituting a healthy diet, sleep hygiene and regular exercise, and addressing smoking and substance use. This is framed against a backdrop of implementing education, psychological and social supports as well as addressing barriers and monitoring outcomes. Care within this phase ‘needs to be undertaken to facilitate functional recovery’; therefore addressing lifestyle behaviours is now positioned as a foundational feature of management (Malhi et al., 2021). This recommended approach to treatment also recognises the need to implement long-term sustainable and preventive lifestyle strategies for mood disorders rather than primarily focusing on management of acute episodes.

How does the application of lifestyle-based care in mental health differ from that offered to other patient populations?

The guidelines also rightly recommended consideration of specific barriers that may be faced when implementing lifestyle-based health care within the context of mood disorders. The varying trajectories of illness means motivation and self-efficacy can be impaired or fluctuate and the guidelines highlight the need for a multidisciplinary approach engaging dietitians and exercise physiologists (among other allied health professionals) to improve adherence. Other considerations for the specific application of lifestyle targeted treatment in mood disorders include the recognition of psychosocial factors, health literacy, (perceived or real) lack of access to resources, side effects of medication regimens and, conversely, the influence of lifestyle change (e.g. smoking cessation) on the effects of psychotropic medication. This speaks to the need for trained, specialist allied health practitioners to help deliver coordinated care, but also to the need for specialised training and upskilling opportunities for mental health care clinicians to learn how to deliver lifestyle-based mental health care. Indeed, meta-analytic evidence shows that the best outcomes arise when dietary interventions are delivered by dietetics professionals (Firth et al., 2019a). However, as noted below, there are no current funding mechanisms that support this type of multidisciplinary care in the Australian mental health context; this will require health policy reform to be effectively implemented.

How do we address the evidence–translation gap?

Of course, the availability of guidelines alone does not ensure uptake by clinicians or the provision of optimal care. To progress the integration of sustainable, evidence-based, lifestyle-based mental health care into routine practice, new models of care are required. Due to the novelty of applying lifestyle-based health care to the mental health setting, exemplars are somewhat limited. However, one such example is the Te Tumu Waiora programme, delivered in New Zealand, which has been highly successful in managing mental health and well-being through the integration of Health Coaches and Health Improvement Practitioners into general practice teams. A further example is the Mind-Body Well-being Initiative in Queensland Australia, which delivers a comprehensive lifestyle-based mental health care programme within a residential mental health service for people with severe mental illnesses (Lalley et al., 2021). As suggested in the 2019 Lancet Commission blueprint for protecting the physical health of people with mental illness (Firth et al., 2019b), an efficient strategy could be to identify lifestyle programmes that have been successfully trialled for physical conditions and translate these programmes to the mental health care setting. The recommended Diabetes Prevention Program includes group and individualised interventions, use of case managers, a core education curriculum, and strategies that address motivation and adherence issues. Regardless of the approach, there is little doubt that successful lifestyle-based models of care will need to be embedded and compatible with existing care structures. We are currently testing such a model in public mental health care, with results due in 2022.

New workforce personnel will likely be required as part of lifestyle-based mental health care. If we again look to diabetes prevention and management as an exemplar, diabetes educators provide an important function in the primary care setting for Australians with diabetes. They are funded by the Medicare benefits scheme to deliver annual cycles of multidisciplinary care. In contrast, allied health professionals, such as dietitians or exercise physiologists, are currently not eligible for reimbursement for mental health referrals, presenting a substantial impediment to the delivery of best practice lifestyle-based mental health care. The siloing of health care according to physical versus mental health needs must be addressed to improve access and outcomes for patients. This is particularly true for behavioural, non-pharmacologic treatments that are complex, multi-factorial and often personalised. Moreover, appropriate reimbursement for mental health care professionals’ time, if they choose to train for and deliver lifestyle-based mental health care, will be critical to successful implementation.

Clinician training in lifestyle-based mental health care

Upskilling and provision of professional education for mental health practitioners in the fundamentals of lifestyle-based mental health care is an obvious first step. Indeed, clinicians widely report a lack of training and confidence as barriers to the successful delivery of lifestyle-based mental health care to their patients. Applying the new knowledge in clinical practice does not need to be complicated; the guidelines for diet, exercise and smoking cessation are similar in mental health as they are for physical health. We note an increasing tendency for some physicians outside of Australia to promote non-evidence-based dietary strategies – such as the ketogenic diet – for mental disorder treatment. Such strategies currently lack appropriate evidence, are not risk-free, and serve to confuse patients and physicians alike. For this reason, further training – including short courses to upskill health care practitioners in evidence-based lifestyle-based mental health care – is warranted. General training regarding lifestyle-based care is available through programmes such as the Smoking, Nutrition, Alcohol, Physical Activity (SNAP) programme; however, this is non-specific to the mental health setting. We are currently engaging with peak bodies to develop accredited training programmes for different practitioner groups to support the application of evidence-based, best practice, lifestyle-based mental health care.

Further guideline development

More detailed clinical guidelines regarding the optimal application of lifestyle-based mental health care, based on current best evidence, are required to complement those provided by the recent RANZCP guidelines. The multitude of often-complex barriers and enablers to effective delivery of lifestyle-based mental health care requires evidence-based resources to support uptake. Physical activity, for example, requires consideration for a range of factors including the frequency, intensity and type (e.g. aerobic vs resistance) of intervention; the setting (leisure vs work-related physical activity); and consideration of patient factors such as previous experience, motivation and physical function. Further guidelines that provide guidance on such details are crucial, particularly in settings where access to allied health practitioners is currently limited. The joint taskforce of the World Federation of Societies for Biological Psychiatry and the Australian Society of Lifestyle Medicine is currently developing such guidelines for depression, scheduled for publication in late 2021, with future guidelines slated for other mental disorders.

Conclusion

In summary, placing lifestyle improvement at the foundation of mental health care is both evidence-based and important to improve both short- and long-term mental and physical health outcomes in psychiatry. The new RANZCP clinical practice guidelines for mood disorders represent a key step in translating the evidence into clinical practice. The identification and evaluation of optimal models of care via large and long-term effectiveness trials, new funding and reimbursement models, the upskilling and training of clinicians, and the development of resources for successful delivery of evidence-based approaches, will all provide further necessary support and impetus to this emerging model of mental health care.