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International Society for Nutritional Psychiatry Research consensus position statement: Nutritional medicine in modern psychiatry

Authors:
LETTER TO THE EDITOR
International Society for Nutritional Psychiatry
Research consensus position statement: nutritional
medicine in modern psychiatry
In recent years, there has been an unprecedented growth
in both the quantity and methodological quality of research
directed at exploring the relationship between nutrition and
mental health. Indeed, the strength of data has now afforded
nutritional medicine a place in the mainstream psychiatric
discourse (1).
Robust associations have been established between nutri-
tional quality and mental health, with the bulk of this evi-
dence indicating a protective effect of healthy diets on
depressed mood (2), and the newest research supporting a
detrimental impact of unhealthy diets on the mental health
of young people (3,4) and adults (5,7).
There are also convincing data supporting the applica-
tion of certain nutrient-based supplements (nutraceuti-
cals) as monotherapy or combined therapy (8), or as aug-
mentation therapy (9).
Although the growth in scientific research related to nutri-
tion in psychiatry may be recent, it is now at a stage where it
can no longer be ignored. In light of this, we aim to provide a
platform to move towards a new integrated paradigm in psy-
chiatry whereby nutritional considerations (both education-
al and prescriptive) can be considered “mainstream” (1). To
this end, we present a consensus position statement from the
International Society for Nutritional Psychiatry Research
(ISNPR).
In brief, the ISNPR was formed in 2013 with the aim to
advance research and communication on nutritional med-
icine in the field of psychiatry. One of its first goals was to
formulate a position statement that embodied the princi-
ples of the organization, allowing for codification of the
society’s underpinning tenets.
In order to develop this, we employed a Delphi-based
model by which ISNPR researcher and clinician members
could vote on a select list of 110 statements created by an
expert steering committee.
The committee provided a list of sub-statements con-
cerning three main topics/areas: the current general needs
and challenges in psychiatry; key elements of diet and
nutraceutical evidence related to mental health/psychia-
try; potential public health and clinical applications. These
were transcribed and tabulated in Survey Monkey for online
voting by the wider ISNPR membership.
A Likert scale (0–10) was used for each statement
(05don’t include, 55don’t know/depends, 105definitely
include), and statements that received a mean score of
>6.5/10 by ISNPR members were reviewed by the steer-
ing committee for inclusion in the position statement,
which is presented below.
Present treatment of mental disorders is achiev-
ing sub-optimal outcomes; in addition little atten-
tion is given to preventative efforts. Due to the
immense burden of mental disorders, there is now
an urgent need to identify modifiable targets to
reduce the incidence of these disorders. Diet and
nutrition offer key modifiable targets for the preven-
tion of mental disorders and have a fundamental
role in the promotion of mental health.
Epidemiological data, basic science, and clinical
evidence suggest that diet influences both the risk
for and outcomes of mental disorders. As such, we
advocate that evidence-based nutritional change
should be regarded as an efficacious and cost-
effective means to improve mental health.
In addition to dietary modification, we recognize
that nutrient-based (nutraceutical) prescription has
the potential to assist in the management of mental
disorders at the individual and population level.
Many of these nutrients have a clear link to brain
health, including: omega-3s, B vitamins (particu-
larly folate and B12), choline, iron, zinc, magne-
sium, S-adenosyl methionine (SAMe), vitamin D,
and amino acids. While we advocate for these to
be consumed in the diet where possible, additional
select prescription of these as nutraceuticals may
also be justified.
Ongoing research (including randomized con-
trolled trials) in the area is recognized as critical,
using methodologically rigorous designs. Further
explication of the biological pathways affected by
nutritional modification is also required. Clinical
trials of nutraceuticals should include assessment
of biomarkers in tandem with clinical outcomes.
Global research and health promotion activities
focused on improving population health should
also include mental health parameters as priority
targets and measured outcomes.
Importantly, the activities of the food industry need
to be examined at a governmental level and relevant
policies designed to reduce the global burden of physi-
cal and mental ill-health attributable to poor diet.
Such policies are advised to stimulate significant pub-
lic change in dietary habits back towards a traditional
wholefood diet (dependent on the culture). Further,
there is now a vital need for better public and clinician
education to communicate current research findings
from the field.
In summary, nutrition and nutraceuticals should
now be considered as mainstream elements of psychi-
atric practice, with research, education, policy, and
health promotion reflecting this new paradigm.
370 World Psychiatry 14:3 - October 2015
As detailed in our consensus statement, we advocate for
the pursuit of an integrative psychiatric model, with diet as a
key element. Further, the select use of evidence-based nutra-
ceuticals should be a mainstay of treatment as either stand-
alone therapies (mainly in cases of less severe mental disor-
ders, non-tolerance to medication, nutrient deficiencies, or
patient choice), or as adjunctive interventions with psycho-
tropic medications to augment treatment efficacy. We recog-
nize the importance of clinician and public education regard-
ing evidence-based nutrition and nutraceuticals to drive
mainstream acknowledgement of their impact on mental
health.
It is the intention that this position statement and the
ongoing work of ISNPR will assist in facilitating a trans-
formation in psychiatry to better address the substantial
global burden of mental illness, recognizing and embrac-
ing diet and nutrition as central determinants of both
physical and mental health.
Jerome Sarris
1,2
, Alan C. Logan
3
, Tasnime N.
Akbaraly
4,5
, G. Paul Amminger
6
, Vicent Balanz
a-
Mart
ınez
7
, Marlene P. Freeman
8
, Joseph Hibbeln
9
,
Yutaka Matsuoka
10
, David Mischoulon
11
, Tetsuya
Mizoue
12
, Akiko Nanri
12
, Daisuke Nishi
13
, Natalie
Parletta
14
, Drew Ramsey
15
, Julia J. Rucklidge
16
,
Almudena Sanchez-Villegas
17,18
, Andrew Scholey
2
,
Kuan-Pin Su
19,20
, Felice N. Jacka
21-24
1
Department of Psychiatry, University of Melbourne,
Melbourne Clinic, Melbourne, Australia;
2
Centre for
Human Psychopharmacology, Swinburne University of
Technology, Hawthorn, Australia;
3
CAMNR, Calabasas,
CA, USA;
4
Inserm U1198, Montpellier, France; EPHE,
Paris, France; University Montpellier 2, Montpellier,
France;
5
Department of Epidemiology and Public
Health, University College London, London, UK;
6
Ory-
gen, The National Centre of Excellence in Youth Men-
tal Health, Australia;
7
Teaching Unit of Psychiatry and
Psychological Medicine, La Fe University and Polytech-
nic Hospital, University of Valencia Medical School,
CIBERSAM, Valencia, Spain;
8
Perinatal and Reproduc-
tive Psychiatry, Massachusetts General Hospital, Bos-
ton, MA, USA;
9
National Institute on Alcohol Abuse
and Alcoholism, NIH, Bethesda, MD, USA;
10
Depart-
ment of Clinical Epidemiology, Translational Medical
Center, National Center of Neurology and Psychiatry,
Tokyo, Japan;
11
Depression Clinical and Research Pro-
gram, Massachusetts General Hospital, Boston, MA,
USA;
12
Department of Epidemiology and Prevention,
National Center for Global Health and Medicine,
Tokyo, Japan;
13
Department of Mental Health Policy
and Evaluation, National Institute of Mental Health,
Japan;
14
School of Population Health, University of
South Australia, Adelaide, Australia;
15
Columbia Uni-
versity College of Physicians and Surgeons, New York,
NY, USA;
16
Department of Psychology, University of
Canterbury, Christchurch, New Zealand;
17
Research
Institute of Biomedical and Health Sciences, University
of Las Palmas de Gran Canaria, Las Palmas de Gran
Canaria, Spain;
18
CIBEROBN, Instituto de Salud Car-
los III, Madrid, Spain;
19
Department of Psychiatry and
Mind-Body Interface Laboratory, China Medical Uni-
versity Hospital, Taichung, Taiwan;
20
Graduate Insti-
tute of Neural and Cognitive Sciences, China Medical
University, Taichung, Taiwan;
21
IMPACT SRC, School
of Medicine, Deakin University, Geelong, 3220, Austra-
lia;
22
Murdoch Children’s Research Centre, Parkville,
Australia;
23
Department of Psychiatry, University of
Melbourne, Royal Melbourne Hospital, Melbourne,
Australia;
24
Black Dog Institute, Road Prince of Wales
Hospital, Randwick, Australia
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DOI 10.1002/wps.20223
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... Our extensive database allowed us to further adjust for these lifestyle factors which slightly attenuated the beneficial effect from MDP. Similarly, metabolic diseases can result in dietary habits which could modulate the risk of depression in turn [7,14]. As obesity is known to stimulate chronic pro-inflammatory status, it is a plausible pathway linking together diet and risk of depression [39]. ...
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Background Depression imposes immense public health burden, demonstrating an urgent need of the identification of modifiable risk factors. Only a few cohort studies have analyzed the association between Mediterranean dietary pattern (MDP) and depression but with mixed results. We examined the impact of MDP on clinically ascertained depression in a large population-based dataset. Methods In 1991/92, detailed information on diet, using a food frequency questionnaire, and potential confounding factors (body weight, height, educational attainment, smoking, previous diabetes and hypertension, and physical activity) was collected, in a random sample of 49,261 Swedish women aged 29-49. Adherence to MDP was calculated. Clinical depression was extracted from the National Patient Register. Study participants were followed up through 2012. Results During an average follow-up of 20.4 years, 1677 incident cases of depression were diagnosed. We observed a lower risk of depression for medium (score 4-5) and high (6-9) adherence to MDP, compared with low (0-3) adherence (Medium: hazard ratio (HR) = 0.90, 95% confidence interval (CI) = 0.81-1.00; High: HR = 0.82, 95%CI = 0.71-0.94). Per unit increase of adherence, the risk of depression was reduced by 5% (HR = 0.95, 95%CI = 0.92-0.98). The association became stronger when restricting to severe form of depression (HR = 0.51, 95%CI = 0.33-0.76). The HRs were higher from age 50 onward both over the first and the second 10-year follow-up period, compared with before age 50, indicating stronger association with increasing age. Results remained after extensive sensitivity analyses. Conclusion Higher adherence to a Mediterranean diet at middle age was associated with a lower risk of depression later in life among Swedish women.
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... Among the modifiable factors, diet is one of the main lifestylerelated factors for mental disorders that individuals are exposed to daily. Of note, the experts from the International Society for Nutritional Psychiatry Research state that "diet and nutrition are central determinants of mental health" (4). It has been increasingly recognized that diet could serve as a key source of inflammation due to the ability of specific food parameters to regulate inflammatory biomarkers (5)(6)(7). ...
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... Recently, epidemiological data have highlighted the association between nutrition and mental health, which raises up more studies in the nascent eld of nutritional psychiatry (6). Although diet has been reported in many studies to potentially prevent or treat mental illness, mostly major depression (7,8), information about the causality or underlying mechanism is still unclari ed. ...
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Diet quality is related to the risk for depression and anxiety in adults and adolescents; however, the possible impact of maternal and early postnatal nutritional exposures on children's subsequent mental health is unexplored. The large prospective Norwegian Mother and Child Cohort Study recruited pregnant women between 1999 and 2008. Data were collected from mothers during pregnancy and when children were 6 months and 1.5, 3, and 5 years of age. Latent growth curve models were used to model linear development in children's internalizing and externalizing problems from 1.5 to 5 years of age as a function of diet quality during pregnancy and at 1.5 and 3 years. Diet quality was evaluated by dietary pattern extraction and characterized as "healthy" or "unhealthy." The sample comprised 23,020 eligible women and their children. Adjustments were made for variables including sex of the child, maternal depression, maternal and paternal age, maternal educational attainment, household income, maternal smoking before and during pregnancy, mothers' parental locus of control, and marital status. Higher intakes of unhealthy foods during pregnancy predicted externalizing problems among children, independently of other potential confounding factors and childhood diet. Children with a high level of unhealthy diet postnatally had higher levels of both internalizing and externalizing problems. Moreover, children with a low level of postnatal healthy diet also had higher levels of both internalizing and externalizing problems. Among this large cohort of mothers and children, early nutritional exposures were independently related to the risk for behavioral and emotional problems in children.
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Key biological factors that influence the development of depression are modified by diet. This study examined the extent to which the high-prevalence mental disorders are related to habitual diet in 1,046 women ages 20-93 years randomly selected from the population. A diet quality score was derived from answers to a food frequency questionnaire, and a factor analysis identified habitual dietary patterns. The 12-item General Health Questionnaire (GHQ-12) was used to measure psychological symptoms, and a structured clinical interview was used to assess current depressive and anxiety disorders. After adjustments for age, socioeconomic status, education, and health behaviors, a "traditional" dietary pattern characterized by vegetables, fruit, meat, fish, and whole grains was associated with lower odds for major depression or dysthymia and for anxiety disorders. A "western" diet of processed or fried foods, refined grains, sugary products, and beer was associated with a higher GHQ-12 score. There was also an inverse association between diet quality score and GHQ-12 score that was not confounded by age, socioeconomic status, education, or other health behaviors. These results demonstrate an association between habitual diet quality and the high-prevalence mental disorders, although reverse causality and confounding cannot be ruled out as explanations. Further prospective studies are warranted.
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Adjuvant use of nutritional and herbal medicines has potential to increase the efficacy of synthetic pharmaceuticals, and perhaps also decrease their side-effects by allowing lower doses to be prescribed. We evaluated current evidence for adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines; and explored novel future areas of research. The paper also critiques current evidence for co-administration of St. John's wort with synthetic antidepressants. We performed a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane database, China National Knowledge Infrastructure and the Chinese Science Citation Database. Search results were supplemented by a review of reference lists and a forward search using the Web of Science. Where possible we calculated effect sizes. Encouraging evidence exists for the use of omega-3 fatty acids, SAMe, folic acid and l-tryptophan adjuvantly with antidepressants to enhance response and improve efficacy. Various nutrients also have emerging evidence as effective adjuncts with antipsychotics and mood stabilizers. While some evidence supports nutritional adjuvancy with various psychopharmacotherapies, adjuvant use of herbal therapies has not been sufficiently studied to warrant standard clinical application. This remains a promising area of research via robust, safety-conscious studies.