Psychosocial treatment

The use of non-pharmacological based treatments to support patients with mental illness is gaining credibility. Psychological treatments or interventions include self-management and related skills training, family interventions, cognitive behaviour therapy, self-help groups, structured counselling, supported housing, supported employment and case management.^(1,2)

Typically treatment will teach new skills and support the patient so that they may have greater control of their environment.

A healthy lifestyle

Lifestyle interventions such as diet and exercise are generating increasing interest, with research supporting their positive outcomes on patients with mental health problems such as depression and anxiety.⁽³⁾ Studies have linked regular exercise of twenty to sixty minutes, at least three times a week, to a reduction in depression.^(3,4,5) Exercise has also had positive outcomes on patients with state and trait anxiety.⁽⁵⁾ Diets low in omega-3 fatty acids, folate, vitamin B12, vitamin B6, zinc, iron, selenium and antioxidants (vitamins C and E) have been linked to depression.^{(3,6,7,8,9,10)} Other lifestyle change recommendations include good sleep hygiene, regular exposure to sunlight and a spiritual or religious experience.⁽⁶⁾

A holistic approach case study

This case study looks at Bonnie’s approach to major depressive disorder (MDD): improving her diet, exercise levels, sunlight exposure, increased sleep and spirituality in conjunction with psychological and social support. To read a full copy of this case study, please refer to the paper by Meyer et al.⁽⁶⁾

Setting the scene

The onset of depression for Bonnie occurred in 1995. Her condition worsened in 2004, with long periods of time in bed, anxiety and feelings of worthlessness and guilt. She struggled to look after her teenage son. Bonnie continued working as a nursing professor during this time, hiding her depression from others and taking medication. Bonnie was eventually diagnosed with MDD and entered a behaviour medicine centre. While Bonnie experienced some improvements, it was not until she attended two lifestyle programs in 2005 (a three-week general lifestyle program and one week of the DRP) that the healing process actually began.

Depression recovery program (DRP)

The depression recovery program was developed by Neil Nedley and takes a holistic approach to recovery. This includes psychotherapy and a focus on physical fitness, nutrition and spirituality. Bonnie lived in the centre for three weeks and her daily routine included therapy (CBT and problem-solving therapy), group therapy, instructional sessions explaining the rationale for treatments, exercise, physical therapy (massage and hydrotherapy), time for spiritual reflection, special meals and cooking classes. Medical evaluations were conducted weekly and fitness testing took place at the beginning and end of the course.

During this time Bonnie was able to reduce her medication significantly, naturally lost significant amounts of weight and improved scores on the anxiety and depression inventories. At the end of the two DRP courses, Bonnie was well equipped to self-manage her illness, taking away with her a self-management plan and a relapse prevention plan.

Holistic management approaches

Bonnie recognised the links between good nutrition and a healthy lifestyle and a healthy body and healthy brain. Depression is almost always caused by multiple factors and therefore treatment which involves multiple methods will be most effective. Bonnie realised that it was the holistic approach to depression (psychotherapy and avoiding negative thinking, social support, diet, physical exercise, religious or spiritual experience, regular restful sleep, bright light) and not diet and exercise alone that resulted in improved outcomes.

The DRP dietary guidelines include the following:⁽¹¹⁾

-       Eat fruit vegetables, beans, nuts and whole grains and avoid, or at least limit, refined foods

-       Eat plant sources of tryptophan

-       Eat foods rich in n-3 PUFAs (or omega-3), at least one meal per day

-       Eat foods providing adequate folic acid and B₁₂.

Bonnie completed a one-hour interval training program daily at the DRP and after a couple of weeks the depression symptoms began to diminish. She currently aims to walk for an hour every day and complements this with stretching and strength training twice a week.

Bonnie aims for thirty minutes of daily sunlight, as research suggests that it increases serotonin production. When sunlight is not naturally available Bonnie uses an artificial light box. She combines re-examining her spiritual beliefs with memorising verses from the bible and listing five things for which she is grateful, daily. Her evening routine includes a warm bath and a light supper to help her achieve a deep sleep.

The future

Bonnie has to follow her program closely to avoid relapse. She now has the skills to cope with challenges and in situations of stress knows that she must be more rigorous in keeping to her program.

Resources

• A Healthy and Active Australia
This site provides a range of information and initiatives on healthy eating, regular physical activity and overweight and obesity to assist all Australians to lead healthy and active lives. It has links to recommended physical activity for 5–12 year olds, 12–18 year olds, adults and older Australians, as well as dietary guidelines.
http://www.healthyactive.gov.au/

• DHB Toolkit: Physical Activity
This is a Ministry of Health Publication which provides New Zealand Physical Activity Guidelines.
http://www.moh.govt.nz/moh.nsf/pagesmh/5535/$File/physical-activity-toolkit.doc

References

1. Mueser KT, Bond GR, Drake RE. Community-Based Treatment of Schizophrenia and Other Severe Mental Disorders: Treatment. MedGenMed 2001;3(1) [formerly published in Medscape Psychiatry & Mental Health eJournal 2001;6(1)]. Available at: http://www.medscape.com/viewarticle/430529
2. National Alliance on Mental Illness. Available from http://www.nami.org/Content/ContentGroups/Helpline1/Psychosocial_Treatments.htm
3. Forsyth A, Deane FP, Williams P. Dieticians and exercise physiologists in primary care: lifestyle interventions for patients with depression and/or anxiety. Journal of Allied Health 2009; 38(2):e63–8.
4. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med.1999;159(19):2349–56.
5. Fox KR. The influence of physical activity on mental well-being. Public Health Nutrition. Cambridge University Press, 2007.
6. Meyer BL, Taylor EJ. A holistic approach to severe depression: my story. Holistic Nursing Practice. Mar–Apr 2008;22(2):81–6.
7. Appleton KM, Hayward RC, Gunnell D, et al. Effects of n-3 long-chain polyunsaturated fatty acids on depressed mood: systematic review of published trials. Am J Clin Nutr. 2006;84(6):1308–16.
8. Fava M. Folate, vitamin B12, and homocysteine in major depressive disorder. Am J Psychiatry 1997;154(3):426–8.
9. Sanchez-Villegas A, Henriquez P, Bes-Rastrollo M, Doreste J. Mediterranean diet and depression. Public Health Nutr. 2006;9(8A):1104–9.
10. Bodnar LM, Wisner KL. Nutrition and depression: implications for improving mental health among childbearing-aged women. Biological Psychiatry 2005; 58(9);679–85.
11. Brown MA, Shirley JL. Enhancing women’s mood and energy: a research-based program for sub-threshold depression using light, exercise, and vitamins. Holist Nurs Pract. 2005;19(6):278–84.