Providing Nutritional Care for Those with Mental Disorders

Is adequate nutrition available to improve neurochemistry?

Posted Oct 15, 2019

My colleague and I recently interviewed a middle-age man to see if he was eligible for a research study. “John” had been treated for depression and anxiety for several years and was responding well to his current antidepressant medication. But he wasn’t so fortunate with other medical problems. He was considerably overweight, drank too much beer on weekends, ate mostly fast food and snacks, and had a variety of painful orthopedic problems that interfered with his sleep and exercise. He was in the process of having his most disabling orthopedic problem attended to, but, as he told us, no one really asked him about his lack of sleep and exercise or food choices and alcohol intake. 

Many of us are aware of how our medical treatment seems to be focused on different body parts, but not enough on ourselves as a unified body and mind. I know an orthopedist who told me he works only on ankles. Problems with toes, feet, knees, or hips required the services of other specialists. 

People with mental disorders may have an additional disadvantage in obtaining medical care that includes both their mental and physical health needs. Their therapist is probably not going to monitor physical symptoms indicative of an on-going medical disorder, or pick up symptoms of a new problem.  And primary care physicians may not have the specialized training and experience to deal with the depression, anxiety, panic disorders, and related mental health problems and the side effects of drugs used to treat these disorders. A paper authored by Dr. Noël and her colleagues points out that it is often hard for a primary care physician to differentiate between symptoms of depression or anxiety and other medical problems that might be causing similar symptoms. They mention that lethargy, for example, can be caused by “…depression, a coexisting medical illness or both.” Disturbances in sleep and appetite may be the consequence of mental illness, drugs for the disorders, or something entirely unrelated. The importance of identifying both mental health disorders and medical problems is important, as the authors discovered in their survey of almost 2000 elderly patients with clinical depression. They found that those individuals had a higher incidence of health problems than a comparable population who were not depressed.

The nutritional adequacy of the diets of individuals with mental illness also may not receive the attention it deserves. For instance, the gentleman we interviewed seemed to live on cookies and cold cuts, and ate a complete meal only during infrequent visits with his adult children. When describing his eating habits, he said, somewhat offhandedly, that maybe he ought to see a nutritionist to learn what he should be eating. One of us asked him if this had been suggested by his psychiatrist, and he asserted no, that it hadn’t.

There are many articles suggesting that nutritional inadequacies contribute to, or indeed are responsible for, depression, and at the very least, potentiate it. However, it is not obvious what is chicken or egg. Does an inadequate consumption of say folate, or omega-three fatty acids, or certain vitamins predispose an individual to depression or bipolar disorder? Or is it possible that as depression progresses before treatment is sought, the nutritional adequacy of the diet declines concomitantly?

Many of us do not eat a nutritionally adequate diet every day, or even more than a couple of times a week. We can instantly find valid reasons for not doing so, with lack of time being offered as the most plausible excuse. But consider the situation of someone who has difficulty leaving the house because of depression, anxiety, or rapid mood swings. Consider the situation of someone who, because of mental illness, can no longer work, relies on public transportation to go to the not very close supermarket, has a limited income, and finds it easier to go to a nearby fast-food chain, rather than preparing meals. Such individuals are not likely to have the motivation, and even the income to seek out foods with valuable nutrients contents like a kale- sweet potato salad, fish with high omega-three fatty acids, high fiber grains and beans, and yogurt with probiotic activity.

Whether or not certain nutrients may help or, by their absence, hinder mental health requires more research.  But chronic undernutrition, that is, the inadequate consumption of necessary nutrients, may affect general well-being in everyone. Many of us will attribute our fatigue or inattentiveness or irritability to some real or perceived inadequacy in our diet: not enough water, too much fat or sugar, or too few B vitamins or protein or probiotics. But if a patient with mental illness complains about rarely feeling that well, the symptoms may be attributed to the mental disorder or side effects of the medication, rather than missing nutrients in the diet.

Unfortunately, it is easier to write about the problem than to find a solution.  Who will ask the patient about his or her diet? What physician or psychologist or psychiatric social worker has the time to ask about the patient’s diet, or in some cases, the expertise in nutrition to evaluate the answers?  Referrals to a dietician are often based on the presence of a metabolic disorder such as diabetes or high blood pressure. Referrals for the purpose of reviewing a patient’s nutritional status would have to depend on the health care provider’s awareness of what the patient is or is not eating.  

One solution could come from national support groups like NAMI ("National Alliance on Mental Illness") whose newsletters, meetings and members support those with mental illness. Alerting their members to the importance of making nutritionally adequate food choices and suggesting that this is an issue to be discussed with their health care providers might help people like “John” eats more healthily.

References

“Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being,”  Hitchcock -Noël, P, 1,2 Williams J, MD, MPH, Unützer, J et al, Ann Fam Med 2004; 2: 555-562.