A family member was admitted to a psychiatric hospital this year with a major depressive episode. For the sake of anonymity lets call her Margie. I investigated the hospital and found that the medical director, chief nursing officer and CEO had excellent credentials. I asked Margie about her food choices, opportunity for exercise and time outdoors. All of these were deplorable. The only opportunity to spend time outdoors was to go outside with the smoking group for 20 minutes twice per day (cigarette breaks). There was no exercise program or exercise opportunity other than walking the halls and walking up and down the stairs with the smoking group going to/from a smoking session. The only green leafy vegetable available was iceberg lettuce (minimal nutritional value). Food options included high sugar and high starch content items, with very few vegetables and fresh fruits. Sugar and refined carbohydrates contribute to inflammation and gut dysbiosis, both of which contribute to psychiatric illness.

Margie had insomnia and depression. These two problems travel together and feed on each other. The lack of outdoor light in the morning and presence of artificial light in the evening all contribute to disruption of  circadian rhythm, worsening depression and insomnia. Lack of exercise also contributes to both.

Here is an excerpt of a letter I sent to her treating psychiatrist with copies to the CEO, medical director and chief nursing officer.

I do have concerns about the lack of availability at XXXXXXXXX Hospital of two essential components to mental health, specifically nutritional support and exercise.

So far the dietician has not yet consulted with XXXXX. I called the dietary department to discuss my concerns that she has been served primarily nutritionally deplete starch and sugar laden foods with a minimum of vegetables, fruit, healthy fat and protein. I was told that the only green leafy vegetable available is lettuce and when I inquired about other vegetables the response was very limited. Bob in the dietary department was great and very receptive to my concerns but seems somewhat limited in the availability of appropriate nutrient dense food at XXXXXXXX.

In addition, Margie tells me that XXXXXXX has no exercise program or exercise facility for patients. The importance of exercise and nutrition has been discussed extensively in the psychiatry literature.

Enclosed are a few review articles and abstracts relevant to nutrition and exercise for in-patient psychiatry. I hope you find these useful and would consider making efforts along the lines of the author’s recommendations in these studies and review articles.

I found the review by Dr LaChance and Dr. Ramsey “Antidepressant foods: An evidence-based nutrient profiling system for depression” to be most informative. You are probably aware that Dr. Ramsey has presented many lectures at the annual meeting of the American Psychiatric Association. The authors of the other studies enclosed have also been well represented at that meeting.

Despite requesting a response from the Medical Director, Chief Nursing Officer, and CEO, I never received any communication in response to my concerns.

The concept of “NUTRITIONAL PSYCHIATRY” has received much attention in the psychiatry literature. This article was published in the World Journal of Psychiatry. Antidepressant foods: An evidence-based nutrient profiling system for depression.

The article discusses nutrients that are “related to the prevention and treatment of depressive disorders”

Here is a summary:

Twelve Antidepressant Nutrients relate to the prevention and treatment of depressive disorders: Folate, iron, long-chain omega-3 fatty acids (EPA and DHA), magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc.

The highest scoring foods were bivalves such as oysters and mussels, various seafoods, and organ meats for animal foods. The highest scoring plant foods were leafy greens, lettuces, peppers, and cruciferous vegetables.

This description aligns with the anti-inflammatory diet that I recommend to patients.

This dietary approach provides essential nutrients for brain health but also provides for healthy diversity in the gut microbiome,.

The relationship between psychiatric illness and the gut microbiome has been extensively reviewed in the medical literature.

This complicated picture depicts the interaction between food, gut microbiome, immune system, inflammation, endocrine system (stress response mediated by the hypothalamic pituitary adrenal axis), nervous system, neuro-transmitters including serotonin (the purported target of many anti-depressant medications). BBB is the blood brain barrier. ENS is the enteric nervous system. SCFAs are short chain fatty acids, very important for health, produced by “good” gut bacteria by using dietary fiber.

SCFAs serve several useful purposes including nourishment for the cells that line the gut, protection of the tight junctions between those cells (prevent leaky gut), direct anti-inflammatory actions and more. Leaky gut leads to an increase in pro-inflammatory substances crossing the gut barrier and entering the body (instead of staying in the gut and leaving with stool) with a cascade of undesirable consequences. LPS (lipopolysaccharides) are bacterial wall toxins that stimulate the immune system and create inflammation. This inflammatory response is a major contributor to death in the setting of systemic infections (sepsis).

If you are interested in understanding this picture you can read the entire article here.

It is clear from this picture that the authors recommend beans and whole grains. I advise  against the consumption of grains and legumes in favor of colorful vegetables which provide for 5-7 times the amount of fiber per calorie compared to grains. Many reasons to avoid grains and legumes have been discussed on the website many times.

Fiber-rich diets are the main fermentable sources for SCFAs which contribute to the attenuation of systemic inflammation by inducing regulatory T cells. (Lucas et al., 2018) and through multiple other mechanisms.

SCFAs are one of many metabolites produced by gut bacteria that contribute to the prevention of depression

The mechanisms of action include direct communication to the brain through the Vagus nerve, absorption of SCFAs into the blood where it can reach the brain and have beneficial effects, dampening of the inflammatory immune response, protecting the gut lining as mentioned above. These are depicted below.

Image Source : Microb Cell 2019 Oct 7,; 6(10): 451-481, PMID 31646148

Exercise protects against depression and is useful as therapy for depression.

In her discussion of depression as a brain inflammatory disorder Psychiatrist Emily Dean describes well some of these interactions.

This is not the first time I have observed  very limited access to nutritious foods, exercise and sunlight in the setting of a psychiatric hospital. Unfortunately, it will likely not be the last despite multiple studies and articles in the medical literature pointing to the importance of these three ingredients for general and psychiatric health.

To prevent and treat depression and other psychiatric illnesses, nutrition, exercise, sunshine are all important. Lack of these basic treatment modalities hampers recovery and health.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose.

Doctor Bob