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

DOI:10.1002/wps.20223
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Jerome Sarris
Jerome Sarris
Jerome Sarris
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Alan C. Logan
Alan C. Logan
Alan C. Logan
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Tasnime Akbaraly at French Institute of Health and Medical Research
Tasnime Akbaraly
Gp Paul Amminger at University of Melbourne
Gp Paul Amminger
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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
References
1. Sarris J, Logan A, Akbaraly T et al. Nutritional medicine as main-
stream in psychiatry. Lancet Psychiatry 2015;2:271-4.
2. Lai JS, Hiles S, Bisquera A et al. A systematic review and meta-
analysis of dietary pattern and depression in community-dwelling
adults. Am J Clin Nutr 2013;99:181-97.
3. O’Neil A, Quirk SE, Housden S et al. Relationship between diet
and mental health in children and adolescents: a systematic
review. Am J Public Health 2014;104:e31-42.
4. Jacka FN, Ystrom E, Brantsaeter AL et al. Maternal and early
postnatal nutrition and mental health of offspring by age 5 years:
a prospective cohort study. J Am Acad Child Adolesc Psychiatry
2013;52:1038-47.
5. Akbaraly TN, Brunner EJ, Ferrie JE et al. Dietary pattern and
depressive symptoms in middle age. Br J Psychiatry 2009;195:
408-13.
6. Sanchez-Villegas A, Delgado-Rodr
ıguez M, Alonso A et al. Asso-
ciation of the Mediterranean dietary pattern with the incidence of
depression: the Seguimiento Universidad de Navarra/University
of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry 2009;
66:1090-8.
7. Jacka FN, Pasco JA, Mykletun A et al. Association of Western and
traditional diets with depression and anxiety in women. Am J Psy-
chiatry 2010;167:305-11.
8. Rucklidge JJ, Kaplan BJ. Broad-spectrum micronutrient formulas
for the treatment of psychiatric symptoms: a systematic review.
Expert Rev Neurother 2013;13:49-73.
9. Sarris J, Kavanagh D, Byrne G. Adjuvant use of nutritional and
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zodiazepines. J Psychiatr Res 2010;44:32-41.
DOI 10.1002/wps.20223
371
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... These neurotransmitters are involved in regulating mood, appetite, and cognition, thus highlighting the importance of adequate nutrient intake for optimal mental health [38][39][40]. The International Society for Nutritional Psychiatry Research has advocated for the integration of nutritional medicine into mainstream psychiatric practice, emphasizing the need for research, education, policy, and health promotion to support this innovative approach [38]. However, the implementation of this framework faces challenges due to the complexity and multidimensional nature of both mental health and nutrition [41]. ...
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Nutritional medicine as mainstream in psychiatry
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Full-text available
  • Jan 2015
Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefi ts in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional defi ciencies) and mental health, and for the select use of nutrient-based supplements to address defi ciencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging fi eld of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.
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Full-text available
  • Oct 2014
We systematically reviewed 12 epidemiological studies to determine whether an association exists between diet quality and patterns and mental health in children and adolescents; 9 explored the relationship using diet as the exposure, and 3 used mental health as the exposure. We found evidence of a significant, cross-sectional relationship between unhealthy dietary patterns and poorer mental health in children and adolescents. We observed a consistent trend for the relationship between good-quality diet and better mental health and some evidence for the reverse. When including only the 7 studies deemed to be of high methodological quality, all but 1 of these trends remained. Findings highlight the potential importance of the relationship between dietary patterns or quality and mental health early in the life span.
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Broad-spectrum micronutrient formulas for the treatment of psychiatric symptoms: A systematic review
Article
Full-text available
  • Jan 2013
Ingesting minerals and vitamins in combination makes physiological sense, and research on the use of broad-spectrum formulations for psychiatric symptoms is increasing rapidly. This review covers formulas consisting of at least four vitamins and/or minerals and includes four experimental designs: randomized controlled trials, open-label trials, case-control studies and case studies with within-subject crossovers. Nevertheless, there is evidence for the efficacy of micronutrients in the treatment of stress and antisocial behaviors as well as depressed mood in nonclinical and elderly populations. Many reports studied mood changes in healthy populations, making it difficult to generalize to clinical samples. There is also preliminary support for the treatment of autism with micronutrients. However, despite positive preliminary findings, there are less data available to support efficacy of micronutrient formulas in treating bipolar disorder, attention deficit-hyperactivity disorder and substance abuse/dependence and no clinical trials have been done with clinically depressed or anxious patient samples, psychosis or eating disorders.
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Dietary pattern and depressive symptoms in middle age
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Studies of diet and depression have focused primarily on individual nutrients. To examine the association between dietary patterns and depression using an overall diet approach. Analyses were carried on data from 3486 participants (26.2% women, mean age 55.6 years) from the Whitehall II prospective cohort, in which two dietary patterns were identified: 'whole food' (heavily loaded by vegetables, fruits and fish) and 'processed food' (heavily loaded by sweetened desserts, fried food, processed meat, refined grains and high-fat dairy products). Self-reported depression was assessed 5 years later using the Center for Epidemiologic Studies - Depression (CES-D) scale. After adjusting for potential confounders, participants in the highest tertile of the whole food pattern had lower odds of CES-D depression (OR = 0.74, 95% CI 0.56-0.99) than those in the lowest tertile. In contrast, high consumption of processed food was associated with an increased odds of CES-D depression (OR = 1.58, 95% CI 1.11-2.23). In middle-aged participants, a processed food dietary pattern is a risk factor for CES-D depression 5 years later, whereas a whole food pattern is protective.
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Association of the Mediterranean Dietary Pattern With the Incidence of Depression: The Seguimiento Universidad de Navarra/University of Navarra Follow-up (SUN) Cohort
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  • Oct 2009
Adherence to the Mediterranean dietary pattern (MDP) is thought to reduce inflammatory, vascular, and metabolic processes that may be involved in the risk of clinical depression. To assess the association between adherence to the MDP and the incidence of clinical depression. Prospective study that uses a validated 136-item food frequency questionnaire to assess adherence to the MDP. The MDP score positively weighted the consumption of vegetables, fruit and nuts, cereal, legumes, and fish; the monounsaturated- to saturated-fatty-acids ratio; and moderate alcohol consumption, whereas meat or meat products and whole-fat dairy were negatively weighted. A dynamic cohort of university graduates (Seguimiento Universidad de Navarra/University of Navarra Follow-up [SUN] Project). A total of 10 094 initially healthy Spanish participants from the SUN Project participated in the study. Recruitment began on December 21, 1999, and is ongoing. Participants were classified as having incident depression if they were free of depression and antidepressant medication at baseline and reported a physician-made diagnosis of clinical depression and/or antidepressant medication use during follow-up. After a median follow-up of 4.4 years, 480 new cases of depression were identified. The multiple adjusted hazard ratios (95% confidence intervals) of depression for the 4 upper successive categories of adherence to the MDP (taking the category of lowest adherence as reference) were 0.74 (0.57-0.98), 0.66 (0.50-0.86), 0.49 (0.36-0.67), and 0.58 (0.44-0.77) (P for trend <.001). Inverse dose-response relationships were found for fruit and nuts, the monounsaturated- to saturated-fatty-acids ratio, and legumes. Our results suggest a potential protective role of the MDP with regard to the prevention of depressive disorders; additional longitudinal studies and trials are needed to confirm these findings.
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A systematic review and meta-analysis of dietary patterns and depression in community-dwelling adults
Article
Studies of single nutrients on depression have produced inconsistent results, and they have failed to consider the complex interactions between nutrients. An increasing number of studies in recent years are investigating the association of overall dietary patterns and depression. This study aimed to systematically review current literature and conduct meta-analyses of studies addressing the association between dietary patterns and depression. Six electronic databases were searched for articles published up to August 2013 that examined the association of total diet and depression among adults. Only studies considered methodologically rigorous were included. Two independent reviewers completed study selection, quality rating, and data extraction. Effect sizes of eligible studies were pooled by using random-effects models. A summary of the findings was presented for studies that could not be meta-analyzed. A total of 21 studies were identified. Results from 13 observational studies were pooled. Two dietary patterns were identified. The healthy diet pattern was significantly associated with a reduced odds of depression (OR: 0.84; 95% CI: 0.76, 0.92; P < 0.001). No statistically significant association was observed between the Western diet and depression (OR: 1.17; 95% CI: 0.97, 1.68; P = 0.094); however, the studies were too few for a precise estimate of this effect. The results suggest that high intakes of fruit, vegetables, fish, and whole grains may be associated with a reduced depression risk. However, more high-quality randomized controlled trials and cohort studies are needed to confirm this finding, specifically the temporal sequence of this association.
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Maternal and Early Postnatal Nutrition and Mental Health of Offspring by Age 5 Years: A Prospective Cohort Study
Article
  • Oct 2013
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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Association of Western and Traditional Diets With Depression and Anxiety in Women
Article
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 with antidepressants, mood stabilizers and benzodiazepines
Article
  • Aug 2009
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.
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