Self-Care for Mental Health Problems in the Time of COVID-19

Millions of people have recently lost their jobs and health insurance benefits because of the COVID-19 pandemic. The result is that many struggling with anxiety, depression, and insomnia cannot afford psychotherapy, medications, or other treatments. The economic fallout of the pandemic may continue for years resulting in prolonged unemployment and an increasing percentage of the population with untreated serious mental health problems.

Politicians and state legislatures are debating on how to fill the gap in health care that is a direct result of the pandemic and programs that will provide adequate mental health care for growing numbers of uninsured may take months or longer to implement. The result will be that many people-in the US and other countries-who would receive conventional treatments such as psychotherapy and medications for mental health problems during normal times will not be able to afford treatment, their symptoms may become worse, affecting overall quality of life, relationships, and academic and work performance.

Even when conventional treatment is unavailable or unaffordable for millions of individuals who are struggling with depressed mood, anxiety and insomnia, simple lifestyle choices can make a significant difference. This article is offered as a concise review of the mental health benefits of changes in diet, physical activity, and a regular mindfulness or mind-body practice for depressed mood, anxiety, and insomnia.

Diet
The relationship between diet and risk of developing depressed mood is multifactorial. Findings from epidemiologic studies suggest that individuals who consume whole foods (as opposed to processed foods and fast food diets) are at reduced risk for depression. For example, individuals who closely adhere to a Mediterranean diet, as well as traditional diets in Norway, Japan, and China, which are rich in vegetables and fish, have a 30% lower risk for depressed mood than those with the lowest rate of adherence to a Mediterranean diet.

A systematic review identified 12 essential nutrients that met criteria for antidepressant efficacy: folate, iron, long-chain omega-3 fatty acids (EPA, DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.¹ Foods with the highest antidepressant food scores (AFS) included oysters and mussels as well as other seafood, organ meats, leafy greens, lettuces, peppers, and cruciferous vegetables such as broccoli, cauliflower, cabbage, kale, and Brussels sprouts.

Deficiencies of select nutrients are associated with increased risk of depressed mood, including certain B vitamins, omega-3 fatty acids, vitamin D, zinc, and magnesium. The B vitamins function as enzyme co-factors that facilitate the synthesis of neurotransmitters implicated in mood regulation such as serotonin, dopamine, and norepinephrine. Foods rich in B-vitamins especially folate, pyridoxine (B-6), and methyl-cobalamin (B-12) may be especially effective against depressed mood. These include whole grains and dark green leafy vegetables. Omega-3s and some B vitamins also have general anti-inflammatory and neuroprotective benefits in the body and brain, which may contribute to their antidepressant effects. Zinc, magnesium and omega-3 fatty acids promote increased synthesis of brain-derived neurotropic factor, which enhances neuroplasticity, resulting in greater resilience of the brain in the face of chronic stress. Increased neuroplasticity may also reduce risk of depressed mood.

In a 12-week single-blind controlled trial 67 individuals with depressed mood symptoms ranging from mild to severe were randomized to a diet support group versus a social support group.² Individuals in the diet support group received seven individual one-hour sessions and were encouraged to follow diets rich in whole grains, vegetables, fruits, legumes, and low-fat dairy foods. They ate more raw unsalted nuts, fish, lean red meats, eggs, and olive oil while reducing intake of sweets, refined cereals, fried foods, processed foods, and sugary drinks. Individuals in the social support group received the same number of sessions, during which they discussed neutral topics of interest, but did not receive psychotherapy, lifestyle advice, or other interventions. At study end, individuals in the diet support group demonstrated significantly greater improvement in depressed mood scores based on standardized outcome measures compared with those in the social support group.

Dietary preferences also play important roles in anxiety. Generalized anxiety is often associated with reactive hypoglycemia, in which blood sugar drops to an abnormally low level following a meal or drink that contains a large amount of sugar resulting in acute anxiety symptoms that can mimic a panic attack. Research findings indicate that individuals who experience heightened anxiety related to reactive hypoglycemia benefit from simple dietary changes including reducing refined sugar and carbohydrate intake, increasing protein intake, and reducing or eliminating caffeine or alcohol.³

Caffeine use is also associated with an increased risk of anxiety. Caffeine consumption increases the levels of epinephrine, norepinephrine, and cortisol in the blood, resulting in feelings of “nervousness” in adults who have no mental health history, feelings of increased generalized anxiety, and in some cases, panic attacks in individuals who are predisposed to anxiety or panic. Many individuals with chronic generalized anxiety report a significant reduction in the severity of anxiety symptoms when they abstain from caffeine. Chronic alcohol abuse can also manifest as hypoglycemia and malnutrition resulting in generalized anxiety and depressed mood.

Finally, on a general level, the microbiome-which consists of microorganisms that naturally populate the large and small intestines-may contribute to both physical and mental health through a variety of mechanisms, including beneficial changes in CNS levels of serotonin and other neurotransmitters implicated in mood regulation. The general health of the digestive system modulates immune functioning and brain activity through the microbiome-gut-brain axis. Recent research findings point to a link between imbalances in bowel microflora, increased inflammation of the mucosal lining of the intestines, and systemic immune dysregulation resulting in increased risk of depressed mood.⁴

Exercise
Findings from animal and human studies suggest that both the immediate and long-term beneficial effects of exercise on mood are mediated by multiple factors that increase brain levels of mood-elevating endorphins, dopamine, norepinephrine, and serotonin, promote neurogenesis, reduce oxidative stress, and enhance immune functioning.⁵ Moreover, regular exercise may promote increased neuroplasticity in certain brain regions, resulting in improved mood.⁶

Regular exercise including aerobic and non-aerobic strengthening exercise has mood-enhancing effects. Individuals who are less sedentary have a reduced risk of both depressed mood and cardiovascular disease.⁷ Regular aerobic exercise may also improve cognitive functioning in chronically depressed individuals who often experience difficulties with thinking and memory.⁸ The results from a meta-analysis of controlled studies (N = 977) of exercise used as a single intervention or in combination with antidepressants support that regular exercise has consistent beneficial effects on depressed mood.⁹ A systematic review of studies on exercise as an add-on therapy in individuals with MDD showed that depressed individuals who exercise regularly respond consistently better than individuals who take an antidepressant but do not exercise.¹⁰

Following a regular exercise program while taking an antidepressant and doing cognitive therapy was found to improve treatment response.¹¹ Moderately depressed individuals who exercise in addition to receiving regular CBT are less depressed and report fewer suicidal thoughts compared with individuals engaged in CBT only.¹² Antidepressants and exercise probably have equivalent effects on moderate depressed mood.¹³ The therapeutic benefits of regular exercise may also be comparable to select complementary and alternative (CAM) treatments of depressed mood such as St John’s Wort (Hypericum perforatum).¹⁴

Findings of open studies suggest that both aerobic exercise and strength training improve anxiety when done on a regular basis.¹⁵ The beneficial effects of exercise on anxiety are similar to those of meditation and regular relaxation. A workout program consisting of at least 20 to 30 minutes of daily exercise can significantly reduce symptoms of generalized anxiety. Findings of a prospective 10-week study of exercise in individuals prone to panic attacks support that regular walking or jogging (4 miles three times a week) reduces the severity and frequency of panic attacks.¹⁶

In addition to its mood enhancing and anxiety reducing effects, regular exercise enhances self-sufficiency and ensures positive social interactions with other people. Regular exercise has also been shown to improve sleep quality in depressed individuals who do not respond to antidepressants.¹⁷ This may be a significant benefit of exercise for general resilience and day-to-day functioning in view of the high prevalence of insomnia in patients who are chronically depressed.

Relaxation, mindfulness, and mind-body practices
Relaxation techniques include sustained deep breathing, listening to calming music, and progressive muscle relaxation. Examples of mindfulness training include different styles of meditation and guided imagery. Mind-body practices involve both body and mind and include taijiquan, qigong, yoga, and other approaches that involve both the mind and the body. Improved capacity for focused attention and reflection have been proposed as important nonspecific psychological benefits of meditation and mind-body practices. The regular practice of meditation or mind-body techniques such as yoga and taijiquan, may be as effective as CBT or antidepressants for moderately severe depressed mood.

Simple relaxation techniques and mind-body practices also have beneficial effects on insomnia. Mind-body approaches that have been looked at in controlled trials of insomnia include progressive muscle relaxation, massage, meditation, desensitization, guided imagery, autogenic training, and hypnosis. Progressive muscle relaxation and sustained deep breathing are especially effective at reducing sleep latency in individuals with chronic insomnia. Listening to relaxing music soon before bedtime can help individuals with insomnia fall asleep quicker. Many individuals who have problems falling asleep because of chronic worrying report improved sleep with guided imagery.

Meditation and guided imagery are probably more effective than progressive muscle relaxation for situational insomnia but are of little benefit for severe insomnia. Individuals with chronic insomnia who use a cognitive-behavioral technique alone or in combination with a benzodiazepine or other sedative-hypnotic drug report that non-pharmacologic or combined approaches are more effective than medications alone. Improved sleep is sustained longer in individuals who use non-pharmacologic or integrative approaches compared with those who take sleep aids only.¹⁸ A meta-analysis found that non-pharmacologic treatments of chronic insomnia are initially more expensive and require more time compared with medication management but lead to sustained benefits and are more cost-effective than drugs alone in the long run.¹⁹

Supportive relationships
Finally, I want to emphasize the importance of relationships. In addition to engaging in healthy lifestyle choices, supportive relationships with friends and family members can provide important buffers to day to day stresses and uncertainties that we will continue to face in these uncertain times. Video calls or phone calls can be very heartening and encouraging even when shelter-in-place orders restrict us from direct contact with family and loved ones.

Disclosures:

Dr Lake is a Psychiatrist in private practice in California. His most recent book is An Integrative Paradigm for Mental Health Care: Ideas and Methods Shaping the Future, Springer 2019.

References:

1. LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. World J Psychiatry. 2018;8:97-104.
2. Jacka FN, O’Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). BMC Med. 2017;151:23.
3. Salzer HM. Relative hypoglycemia as a cause of neuropsychiatric illness. J Natl Med Assoc. 1966;58:12-17.
4. Cheng LH, Liu YW, Wu CC, et al. Psychobiotics in mental health, neurodegenerative and neurodevelopmental disorders. J Food Drug Anal. 2019;27:632‐648.
5. Schuch FB, Deslandes AC, Stubbs B, et al. Neurobiological effects of exercise on major depressive disorder: a systematic review. Neurosci Biobehav Rev. 2016;61:1‐11.
6. Gourgouvelis J, Yielder P, Murphy B. Exercise promotes neuroplasticity in both healthy and depressed brains: an fMRI pilot study. Neural Plast. 2017;2017:8305287.
7. Schuch F, Vancampfort D, Firth J, et al. Physical activity and sedentary behavior in people with major depressive disorder: a systematic review and meta-analysis. J Affect Disord. 2017;210:139‐150.
8. Oertel-Knöchel V, Mehler P, Thiel C, et al. Effects of aerobic exercise on cognitive performance and individual psychopathology in depressive and schizophrenia patients. Eur Arch Psychiatry Clin Neurosci. 2014;264:589‐604.
9. Kvam S, Kleppe CL, Nordhus IH, Hovland A. Exercise as a treatment for depression: a meta-analysis. J Affect Disord. 2016;202:67‐86.
10. Mura G, Moro MF, Patten SB, Carta MG. Exercise as an add-on strategy for the treatment of major depressive disorder: a systematic review. CNS Spectr. 2014;19:496‐508.
11. Gourgouvelis J, Yielder P, Clarke ST, et al. Exercise leads to better clinical outcomes in those receiving medication plus cognitive behavioral therapy for major depressive disorder. Front Psychiatry. 2018;9:37.
12. Abdollahi A, LeBouthillier DM, Najafi M, et al. Effect of exercise augmentation of cognitive behavioural therapy for the treatment of suicidal ideation and depression. J Affect Disord. 2017;219:58‐63.
13. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587‐596.
14. Ernst E, Rand JI, Stevinson C. Complementary therapies for depression: an overview. Arch Gen Psychiatry. 1998;55:1026‐1032.
15. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. Sports Med. 2000;29:167‐180.
16. Stevinson, C. Exercise may help treat panic disorder. Focus Alt Comp Ther. 1999;4:84-85.
17. Rethorst CD, Sunderajan P, Greer TL, et al. Does exercise improve self-reported sleep quality in non-remitted major depressive disorder? Psychol Med. 2013;43:699‐709.
18. Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999;281:991‐999.
19. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;151:1172‐1180.