Mental health conditions impact us all, whether we suffer from them directly or indirectly.
They contribute to distress on the personal level, in the workplace, and in the public health sector. The National Institute of Mental Health cites depression as the leading cause of disability in the United States in people aged 15 to 44 years old, and sequelae from depression are the primary contributors to work absence and reduced productivity.
Prescription pads across the Western world have practically become arthritic with the steady rise of antidepressant drugs being handed out as if by routine. Meanwhile, clinical efficacy of these drugs has been called into question for over a decade, and their use is associated with numerous potential side effects that may too contribute to disability.10
A 2010 meta-analysis published in the Journal of the American Medical Association reported that “the magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms.” 2
This minimal to nonexistent benefit likely applies to majority of said prescriptions being given.
Conventional treatments, including pharmacologic interventions, have their necessary place in the treatment of mental health disorders, especially in more severe presentations.
There is also a clear growing need for adjunctive therapies, with a more nuanced approach. An integrative approach to addressing mental health issues, which takes into account foundational aspects of wellness such as nutrition, physical fitness, and mind-body connection, while still observing conventional standards of care, is supported both by the research and by common sense.
To state it simply: we need more options. For the sake of brevity and focus—while many more articles can be written to give deeper elucidation into dietary, lifestyle, and mind-body approaches to mental health disorders—the following highlights one fundamental element of mental wellness from an integrative perspective: key micronutrients that are integral to brain function.
Micronutrients Involved in Neuropsychiatric Health
The biochemical processes in the brain and body that determine mental health require a number of micronutrients, many of which are found to be deficient in the diets and blood samples of those with mental health disorders.
The conventional standards of care for mental health disorders rarely include testing of or treatment with these essential micronutrients, though adjunctive nutrient therapy has been shown to improve pharmacotherapy outcomes.
Moreover, many pharmaceutical medications prescribed for various health conditions are known to deplete certain micronutrients that when deficient may manifest in psychiatric symptoms.
For example, Metformin, a common medication used in the treatment of type II diabetes mellitus, depletes vitamin B12; low B12 levels are associated with depression, memory loss, and cognitive dysfunction. Vitamin B12 replenishment may also contribute to better treatment outcomes in those taking antidepressant medications. This makes sense, given that vitamin B12 is a cofactor required in the production of neurotransmitters, the brain chemicals involved in neurotransmission and mood formation.5
Folate, another B-vitamin required in proper neurotransmitter production and cellular function as well as neural tube formation in utero, is frequently found to be low in predominant diets in several countries, despite fortification.
Rich dietary sources of folate include green leafy vegetables, beans, legumes, and whole grains like brown rice and quinoa. Folate deficiency has been associated with reduced treatment response to SSRI antidepressant medications, while folate supplementation has been shown to improve response to these drugs.1,11
Iron deficiency, especially common in young children and menstruating women, may impair neurotransmitter synthesis, weaken immune response, and create such symptoms as fatigue, poor concentration, and apathy.
Children with iron deficiency are also at increased risk for lead toxicity, which may too manifest with neuropsychiatric symptoms of depression or learning problems. These symptoms are usually easily reduced with iron supplementation and inclusion of dietary sources of iron-rich foods, such as red meats, green leafy vegetables, and foods cooked in a cast iron skillet.
Magnesium, a mineral found in green vegetables, nuts, and unrefined whole grains, is involved in hundreds of biochemical reactions in the body. Magnesium deficiency, also known as hypomagnesemia, is a frequently overlooked health concern. Magnesium intake is commonly low in many Western diets, and deficiency may occur secondary to loss as a result of poor absorption, chronic diarrhea, celiac disease, and diabetes.
Deficiency symptoms include anxiety, depression, sleep disturbance, irritability, and restless legs syndrome. Animal models have observed antidepressant-like effects of magnesium supplementation.13 Inverse associations between magnesium intake and standardized depression scores have been demonstrated in larger population studies.7
Cultures that consume large amounts of fish are found to have lower incidence of depression.8 This finding is likely associated with the rich content of both vitamin D and omega-3 fatty acids in fish. Both nutrients are integral to healthy brain function and are frequently found to be low on laboratory studies in the general population.
An estimated 1 billion people worldwide have vitamin D deficiency or insufficiency, especially individuals with darker skin, as reported by the National Health and Nutrition Examination Survey (NHANES).4,6 Every tissue in the body has vitamin D receptors, including the brain, and deficiency can have both physical and psychological consequences. Vitamin D acts as a hormone in the body, activating genes involved in brain function and development. Several studies suggest an association between seasonal affective disorder (SAD) and changing levels of vitamin D during darker months.12
Vitamin D levels can be monitored with blood testing and adjusted with appropriate supplementation, as guided by a healthcare professional. Optimizing vitamin D and omega-3 fatty acid levels may help to treat and prevent mental health disorders and other patterns of brain dysfunction. Omega-3 fatty acids, the “good fats” found in fish, walnuts, flax and chia seeds, are well-studied for their positive impact on mood and brain function.
An inverse relationship is found between intake of omega-3 fatty acids and depression, among other mental health symptoms.Omega-3 fatty acids have anti-inflammatory effects, which have been theorized as a mechanism of action in treating the underlying etiology of depression.
Furthermore, while some meta-analyses have exhibited mixed results in terms of using omega-3 fatty acids as a monotherapy in the treatment of depression, it is clear that they help to improve pharmacotherapy and are at least clearly beneficial as an adjunctive therapy.3,9
Proper nutrition is integral to mental and neurologic health, as supported by a robust canon of evidence and numerous cases seen in practice. While drugs are necessary in some and need not be fully dismissed, much can be said, not to mention disputed, in terms of how we approach mental health both medically and in popular culture.
The subject is deeply steeped in stigma and limitation, with many patients and providers alike wanting more options. The goal here is to add to the conversation about what it means to take a more integrative, more careful approach to prescribing various treatments for mental health disorders, firstly addressing the building blocks.
It has consistently been my clinical observation that when we address the foundational determinants of health (i.e. diet and nutrition, sleep, physical activity, relationships, and environment), patients get better. Furthermore, positive patient outcomes are best achieved when both conventional and integrative providers can unify as a collaborative team.
The options are available, and they are evidence-based. It is the paradigm that can become more expansive, if given the deserved time and energy.
- Alpert JE, Mischoulon D, Rubenstein GE, Bottonari K, Nierenberg AA, Fava M. Folinic acid (Leucovorin) as an adjunctive treatment for SSRI-refractory depression. Ann Clin Psychiatry. 2002;14(1):33-38.
- Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47-53.
- Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. J Clin Psychiatry. 2006:67(12):1954-1967.
- Harris SS. Vitamin D and African Americans. The Journal of Nutrition. 2006 Apr;136(4):1126-1129.
- Hintikka J, Tolmunen T, Tanskanen A, Viinamäki H. High vitamin B12 level and good treatment outcome may be associated in major depressive disorder. BMC Psychiatry. 2003 Dec 2;3:17.
- Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266-281.
- Jack FN, Overland S, Stewart R, Tell GS, Bjelland I, Mykletun A. Association between magnesium intake and depression and anxiety in community-dwelling adults: the Hordaland Health Study. Aust N ZJ Psychiatry. 2009;43(1):45-52.
- Li F, Liu , Zhang D. Fish consumption and risk of depression: a meta-analysis. J Epidemiol Community Health. 2016 Mar;70(3):299-304.
- Lin PY, Su KP. A meta-analytic review of double-blind, placebo-controlled trials of anti-depressant efficacy of omega-3 fatty acids. J Clin Psychiatry. 2007;68(7):1056-1061.
- Moore M, Yuen HM, Dunn N, Mulle MA, Maskell J, Kendrick T. Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database. BMJ.2009;339:b3999.
- Roberts SH, Bedson E, Hughes D, et al. Folate augmentation of treatment – evaluation for depression (FolATED): protocol of a randomized controlled trial. BMC Psychiatry. 2007 Nov 15;7:65.
- Sabir MS, Haussler MR, Mallick S, Kaneko I, Lucas D, Haussler C, Whitfield GK, Jurutka PW. Optimal vitamin D spurs serotonin: 1,25-dihydroxyvitamin D represses serotonin reuptake transport (SERT) and degradation (MAO-A) gene expression in cultured rat serotonergic neuronal cell lines. Genes Nutr. 2018 Jul 11;13:19.
- Szewcyk B, Poleszak E, Sowa-Kuma M, et al. Antidepressant activity of zinc and magnesium in view of the current hypotheses of antidepressant action. Pharmacol Rep. 2008;60(5):588-589
About the Author
Dr. Ana Ruediger practices in Santa Monica, California, focused on providing individualized interventions for her patients (http://anaruediger.com/). She earned her medical and counseling psychology degrees at Bastyr University in Seattle, Washington. In addition to her primary care residency training, she has specialized training in integrative addiction and mind-body medicine. She completed an internship in a dual-diagnosis inpatient treatment facility for patients in addiction and mental health disorders recovery. Dr. Ruediger leads with the philosophy that all people can benefit from being heard, and an individualized, whole-person approach can empower patients to make changes to achieve optimal well-being.