Short of Prescribing Salmon, Docs Use Diet to Boost Mental Health

Deborah L. Cabaniss, MD; Drew Ramsey, MD


September 23, 2019

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This transcript has been edited for clarity.

Deborah Cabaniss, MD: I'm Deborah Cabaniss, professor of clinical psychiatry at Columbia University, and I'm here talking with Dr Drew Ramsey about nutritional psychiatry.

Drew Ramsey, MD: Hi, Deb. Good to see you again.

Cabaniss: Nice to see you. When people think about improving their mental or emotional health, they generally think about whether they should take medication or go into psychotherapy. But you've been talking and writing about the idea that they should think about changing what they eat. Tell us more about that.

Ramsey: Lifestyle interventions appeal to patients. How can we have people more actively thinking about their mental health—specifically, their brain health? There's been a surge of interest in food over the past 10 or 15 years in America, and psychiatry is an opportunity to put ourselves in that house.

On some levels, it's common sense: Your brain is made of food. It also feels like an intervention because patients are eating every day. In general, Americans are not eating foods that anyone would agree are great for their brain.

Is there an opportunity for us in psychiatry to help instruct or guide patients toward foods that are better for their brain and mental health? Increasingly, data have come out suggesting that we may have an opportunity.

Evidence Supporting a Brain-Healthy Diet

Cabaniss: Beyond common sense, what evidence suggests that certain kinds of food or eating differently can make people feel better in terms of their mental health?

Ramsey: I think about the data in three camps. There's the basic bench science of looking at things like omega-3 fatty acids, or B vitamins, and how those work in the body, how they influence neural plasticity and BDNF [brain-derived neurotrophic factor].[1,2]

The second cluster is correlational data looking at our dietary patterns, and how that influences depression risk. A number of studies find [that people who eat] the Mediterranean diet—the whole food or traditional diet, or as some people say, "the food your grandmother used to eat"—tend to have a reduced risk of depression.[3,4] Some studies have found a 50% reduction in risk.[5]

The final segment, the holy grail, of data are randomized trials. Four completed trials have directly assessed depression.[6,7,8,9] Some studies in dementia have found that these diets may be effective interventions. The SMILES trial was one of the best and the first to look at a Mediterranean dietary pattern.[6] When you add a Mediterranean-style diet to treatment, about a third of patients go into full remission.

Cabaniss: Wow. But the MooDFOOD trial did not demonstrate that changing diet prevents depression in a high-risk group.[7] Does that change what you're saying?

Ramsey: I think it's evidence, and I'm excited to see more evidence. MooDFOOD is a consortium of European Union countries looking at these types of questions: How can nutrition influence mental health outcome? This was a large trial, about 1000 individuals, trying to prevent depression in a high-risk population. What was interesting, and one of the reasons why the trial probably didn't work, is that they didn't have a lot of depression in the group—about 10% across the board—whether they were giving folks placebo, a multivitamin, or nutritional counseling.

I think it's a piece of data and I think it illustrates that this isn't a silver bullet. That's often where the data and the idea of nutritional psychiatry get a little overextended. But I do believe in getting involved in how our patients take care of themselves every day with the exercise, mindfulness, and sleep hygiene.

Empowering Patients to Choose Healthy Foods

Cabaniss: So, this is adjunct. You're not necessarily suggesting that dietary changes alone would treat any entity but that it would add on to other types of treatments.

Ramsey: I invite clinicians to think about it as a tool in their toolbox. It's great for building alliance. It shows that there are ways we can empower patients. They rely on me to give them psychotherapy and medications, whereas they can live a lifestyle that promotes better mental health. Those are things they can do for themselves. We can encourage them to think about their brain/mental health every day, "with every bite," as I like to say.

The other thing is, patients can struggle with time commitment and costs of psychotherapy. Medications have side effects, and a lot of patients don't want to be on medicines. In that scenario, I still want to have some moves clinically that are based on some evidence. Food is a nice invitation to get people started on thinking about their mental health and ways they can improve their everyday lives.

Cabaniss: In everyday life, when I go to the supermarket, I'm generally thinking about heart health, and you're saying I should think about brain health. What are three of the major foods that you recommend people eat? What are your general recommendations?

Ramsey: Our clinic has moved toward what we call "food categories." Instead of recommending that you eat kale or wild salmon, those are part of food categories such as leafy greens, which are nutrient-dense and full of healthy nutrition for the brain. Or in the seafood category, wild salmon is a wonderful choice, but so are oysters and mussels.

Cabaniss: What's in them that you like for the brain?

Ramsey: For the seafood category, this is the only place that we find the long-chain omega-3 fatty acid DHA (docosahexaenoic acid), the only omega-3 fat that gets transported into the brain, and it is a very important structural fat in the brain. Women with more DHA have a much lower risk for postpartum depression. There's a lot of correlational data like that.

Leafy greens are a great way to increase the nutrient density of your diet. People focus so much on calories or cholesterol and saturated fat. You could argue that those interventions haven't worked from a public health messaging standpoint. When I tell you not to eat cholesterol, I'm not helping you decide what foods to eat.

As psychiatrists, we're great at motivating people to make behavioral changes. We're good at helping people with individual choices that are important in diet. You can't tell a patient to go home and start eating a Mediterranean diet. Where I'm from, that means people are going to start eating pizza, pasta, and heroes. We want to help people with specific foods and food categories.

Cabaniss: As a psychiatrist and not a specialist in [nutritional psychiatry], should I be talking to my patients about this? Should I refer them to someone like you or to a nutritionist?

Ramsey: I think that's up to us as clinicians. It's a very enjoyable conversation to begin having. Everyone who's a mental health professional needs to assess someone's diet on an intake, just for basic medical purposes. If you're treating someone who is living a vegan lifestyle, they're not eating any B12, so if you don't check in (eg, "Are you on a supplement?" or "What are the rules you're following in your diet?"), you're missing a major piece of that person's psychiatric history.

Bringing Up Diet With Patients

Cabaniss: How would I bring it up? What would be a good entrance into that?

Ramsey: I bring it up gently, by suggesting that a lot of lifestyle factors play a role in mental health. I ask people about their movement or exercise and sleep hygiene. Then I say, "There's been a lot of recent research on how food affects our mental health. Tell me a little bit about your diet." I do what I call a simple food assessment. I ask them to walk through their day in eating. "When you wake up, what do you eat? What's your dietary pattern look like?"

Ramsey: How do you tell them why you're asking them? How do you frame it in terms of brain and emotional health?

Ramsey: I say that our mental health is made up of a lot of small decisions that we make. Some things we can't influence. We can't change our genetics, but we can change how our genes get expressed. If you think about an environmental factor you probably have the most control over, it's your food. From an epigenetic standpoint, it presents an opportunity to get people interested in how our everyday life actions and decisions like diet influence our overall emotional and mental health.

Cabaniss: Are there a couple of top molecules that you tend to talk to people about?

Ramsey: I tend to talk to people about the food, because I think that when we tell people, "Eat more magnesium" they—both patients and physicians—don't know where to find the magnesium. We try to emphasize nutrient-dense foods like leafy greens, nuts and beans, seafood, a little dark chocolate.

Cabaniss: Do they tend to get into recipes with you?

Ramsey: Sometimes. It's very fun to have patients come in and say, "I made salmon for the first time because of you" or "I thought about you the other night when I ordered mussels."

One thing I've enjoyed in my practice is the levity and the enjoyment that it brings to whatever is happening in treatment. My patients and I are eaters, and we enjoy food. You can have a lot of interesting conversations.

One tip is, I encourage clinicians to lose their biases about food. My job isn't to tell you to eat a vegetarian diet or the paleo diet. My job as a nutritional psychiatrist is to help understand what motivates you around food. What are the factors that are important to you? Maybe there are moral factors—for example, you are against animal cruelty and don't want to eat any meat. Or maybe there are certain foods that you've lost touch with—you've immigrated and lost touch with your food and country of origin. These factors relate to your mental health.

Tailoring the Food Conversation, and Looking Ahead to Prevention

Cabaniss: Is this about brain health in general? Or, for example, would you have one kind of food conversation with a depressed person and another kind of food conversation with an anxious person?

Ramsey: I think, overall, that most brain food is pretty similar, and the data are most clear about depression and dementia. However, I would have a slightly different conversation, for example, when patients are anxious. Often those anxieties can stem from food sensitivities. Or anxiety can worsen, for example, when people don't eat. A lot of my patients will have panic attacks midday. What happened? "I didn't eat lunch" or "I just ate a bunch of garbage for lunch."

I've seen clinically that as you get people involved in a better system of eating and help them think through and plan, a lot of food-related anxiety damps down. But in terms of specific foods for specific conditions, I think that's one of the mistakes people tend to make. I see it as an overextension of the data that it's all about food. ("You're depressed again; it must be because you didn't have a kale salad yesterday.") That kind of irks me because it oversimplifies psychiatric illnesses. In some ways, it frames food as the silver bullet, whereas I think food is a foundational element of our health and our mental health.

Cabaniss: I like the way you talk about it. You're talking about setting up somebody for a healthy-brain lifestyle, not necessarily just treating symptoms.

Ramsey: I think that our field needs to do a better job of meeting people earlier. Like you, I meet a lot of patients when they're in a crisis. We like that work, we're good at that work, and we know we can be helpful in that setting. But wouldn't it be nice to have a better set of answers for the public? What can you do in your life to help prevent low moods or anxiety? Because we all struggle with our mood and anxiety at different times in our lives. The more tools we can give patients and the public, the better job we're doing as psychiatrists.

Cabaniss: Thanks. This has been so interesting. I'm Deborah Cabaniss for Medscape and Columbia Psychiatry. Happy eating.

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