Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce

Abstract

Objectives: The primary objectives of these international guidelines were to provide a global audience of clinicians with (a) a series of evidence-based recommendations for the provision of lifestyle-based mental health care in clinical practice for adults with Major Depressive Disorder (MDD) and (b) a series of implementation considerations that may be applicable across a range of settings.

Methods: Recommendations and associated evidence-based gradings were based on a series of systematic literature searches of published research as well as the clinical expertise of taskforce members. The focus of the guidelines was eight lifestyle domains: physical activity and exercise, smoking cessation, work-directed interventions, mindfulness-based and stress management therapies, diet, sleep, loneliness and social support, and green space interaction. The following electronic bibliographic databases were searched for articles published prior to June 2020: PubMed, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), CINAHL, PsycINFO. Evidence grading was based on the level of evidence specific to MDD and risk of bias, in accordance with the World Federation of Societies for Biological Psychiatry criteria.

Results: Nine recommendations were formed. The recommendations with the highest ratings to improve MDD were the use of physical activity and exercise, relaxation techniques, work-directed interventions, sleep, and mindfulness-based therapies (Grade 2). Interventions related to diet and green space were recommended, but with a lower strength of evidence (Grade 3). Recommendations regarding smoking cessation and loneliness and social support were based on expert opinion. Key implementation considerations included the need for input from allied health professionals and support networks to implement this type of approach, the importance of partnering such recommendations with behaviour change support, and the need to deliver interventions using a biopsychosocial-cultural framework.

Conclusions: Lifestyle-based interventions are recommended as a foundational component of mental health care in clinical practice for adults with Major Depressive Disorder, where other evidence-based therapies can be added or used in combination. The findings and recommendations of these guidelines support the need for further research to address existing gaps in efficacy and implementation research, especially for emerging lifestyle-based approaches (e.g. green space, loneliness and social support interventions) where data are limited. Further work is also needed to develop innovative approaches for delivery and models of care, and to support the training of health professionals regarding lifestyle-based mental health care.

Keywords: Major depressive disorder; guidelines; lifestyle; mental health; treatment.

Figure 1.. Conceptual framework for lifestyle-based mental health care.

A proposed clinical flowchart for lifestyle-based mental health care using a 4 A’s (Assess, Advise, Assist, Arrange) structure. Each lifestyle intervention is color coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).

Figure 2.

Guideline recommendations development process

Figure 3.. Core implementation considerations, factors, and lifestyle interventions for lifestyle-based mental health care.

To yield the greatest benefits from lifestyle-based mental health care, it requires personalized individual and group clinical approaches enabled by health service and model of care innovation including health coaching, digital technology, interdisciplinary teams, group and peer-based supports, adapted in the context of socio-economic, cultural and environmental determinants. Each lifestyle intervention is color coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).

Figure 4.. Stepped Care Model of lifestyle-based mental health care.

Lifestyle and psychological approaches are to be discussed with all people with Major Depression Disorder. Lifestyle assessment and interventions can be considered core and foundational components of care based on their strong safety profile and evidence of effect on mental, physical and social wellbeing. These approaches can be combined with other evidence-based therapies with the goal of functional recovery.

Figure 5.. A Swiss cheese model of Lifestyle-based mental health care.

Lifestyle-based mental health care is not a single intervention but rather several mutually supportive and interacting approaches that involve lifestyle domains (covered in section 5) combined with models of care including interdisciplinary teams, peers and carers, health coaching behavior change approaches, and digital technology (covered in section 7). The more each of these layers are cultivated and built within a person’s life and environments, the greater the likelihood of preventing disease progression, enhancing resilience against adverse internal or external events, and improving mental, physical and social wellbeing. This is illustrated by disease progression (thick black line) being mitigated by the additional layers of lifestyle approaches and implementation considerations. Each lifestyle intervention is color coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).