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Lifestyle and mental health
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American Psychologist, 66(7)
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Walsh, RN
Publication Date
2011
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University of California
Lifestyle and Mental Health
Roger Walsh
University of California, Irvine College of Medicine
Mental health professionals have significantly underesti-
mated the importance of lifestyle factors (a) as contributors
to and treatments for multiple psychopathologies, (b) for
fostering individual and social well-being, and (c) for
preserving and optimizing cognitive function. Conse-
quently, therapeutic lifestyle changes (TLCs) are underuti-
lized despite considerable evidence of their effectiveness in
both clinical and normal populations. TLCs are sometimes
as effective as either psychotherapy or pharmacotherapy
and can offer significant therapeutic advantages. Important
TLCs include exercise, nutrition and diet, time in nature,
relationships, recreation, relaxation and stress manage-
ment, religious or spiritual involvement, and service to
others. This article reviews research on their effects and
effectiveness; the principles, advantages, and challenges
involved in implementing them; and the forces (economic,
institutional, and professional) hindering their use. Where
possible, therapeutic recommendations are distilled into
easily communicable principles, because such ease of com-
munication strongly influences whether therapists recom-
mend and patients adopt interventions. Finally, the article
explores the many implications of contemporary lifestyles
and TLCs for individuals, society, and health professionals.
In the 21st century, therapeutic lifestyles may need to be a
central focus of mental, medical, and public health.
Keywords: lifestyle, therapeutic lifestyle changes, mental
health, psychopathology, cognitive capacities
T
he central thesis of this article is very simple: Health
professionals have significantly underestimated the
importance of lifestyle for mental health. More spe-
cifically, mental health professionals have underestimated
the importance of unhealthy lifestyle factors in contributing
to multiple psychopathologies, as well as the importance of
healthy lifestyles for treating multiple psychopathologies,
for fostering psychological and social well-being, and for
preserving and optimizing cognitive capacities and neural
functions.
Greater awareness of lifestyle factors offers major
advantages, yet few health professionals are likely to mas-
ter the multiple burgeoning literatures. This article there-
fore reviews research on the effects and effectiveness of
eight major therapeutic lifestyle changes (TLCs); the prin-
ciples, advantages, and challenges involved in implement-
ing them; the factors hindering their use; and the many
implications of contemporary lifestyles for both individuals
and society.
Lifestyle factors can be potent in determining both
physical and mental health. In modern affluent societies,
the diseases exacting the greatest mortality and morbidity—
such as cardiovascular disorders, obesity, diabetes, and
cancer—are now strongly determined by lifestyle. Differ-
ences in just four lifestyle factors—smoking, physical ac-
tivity, alcohol intake, and diet—exert a major impact on
mortality, and “even small differences in lifestyle can make
a major difference in health status” (Khaw et al., 2008, p.
376).
TLCs can be potent. They can ameliorate prostate
cancer, reverse coronary arteriosclerosis, and be as effec-
tive as psychotherapy or medication for treating some
depressive disorders (Frattaroli et al., 2008; Pischke, Scher-
witz, Weidner & Ornish, 2008; Sidhu, Vandana, & Balon,
2009). Consequently, there is growing awareness that con-
temporary medicine needs to focus on lifestyle changes for
primary prevention, for secondary intervention, and to em-
power patients’ self-management of their own health.
Mental health professionals and their patients have
much to gain from similar shifts. Yet TLCs are insuffi-
ciently appreciated, taught, or utilized. In fact, in some
ways, mental health professionals have moved away from
effective lifestyle interventions. Economic and institutional
pressures are pushing therapists of all persuasions toward
briefer, more stylized interventions. Psychiatrists in partic-
ular are being pressured to offer less psychotherapy, pre-
scribe more drugs, and focus on 15-minute “med checks,”
a pressure that psychologists who obtain prescription priv-
ileges will doubtless also face (Mojtabai & Olfson, 2008).
As a result, patients suffer from inattention to complex
psychodynamic and social factors, and therapists can suffer
painful cognitive dissonance and role strain when they
shortchange patients who need more than what is allowed
by mandated brief treatments (Luhrmann, 2001).
A further cost of current therapeutic trends is the
underestimation and underutilization of lifestyle treatments
(Angell, 2009) despite considerable evidence of their ef-
fectiveness. In fact, the need for lifestyle treatments is
growing, because unhealthy behaviors such as overeating
and lack of exercise are increasing to such an extent that the
World Health Organization (2008, para. 1) warned that “an
escalating global epidemic of overweight and obesity—
‘globesity’—is taking over many parts of the world” and
This article was published Online First January 17, 2011.
Correspondence concerning this article should be addressed to Roger
Walsh, Department of Psychiatry and Human Behavior, University of
California College of Medicine, Irvine, CA 92697-1675. E-mail:
rwalsh@uci.edu
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© 2011 American Psychological Association 0003-066X/11/$12.00
Vol. 66, No. 7, 579–592 DOI: 10.1037/a0021769
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
exacting enormous medical, psychological, social, and eco-
nomic costs.
Advantages of Therapeutic Lifestyle
Changes
Lifestyle changes can offer significant therapeutic advan-
tages for patients, therapists, and societies. First, TLCs can
be both effective and cost-effective, and some—such as
exercise for depression and the use of fish oils to prevent
psychosis in high-risk youth—may be as effective as phar-
macotherapy or psychotherapy (Amminger et al., 2010;
Dowd, Vickers, & Krahn, 2004; Sidhu et al., 2009). TLCs
can be used alone or adjunctively and are often accessible
and affordable; many can be introduced quickly, some-
times even in the first session (McMorris, Tomporowski &
Audiffren, 2009).
TLCs have few negatives. Unlike both psychotherapy
and pharmacotherapy, they are free of stigma and can even
confer social benefits and social esteem (Borgonovi, 2009).
In addition, they have fewer side effects and complications
than medications (Amminger et al., 2010).
TLCs offer significant secondary benefits to patients,
such as improvements in physical health, self-esteem, and
quality of life (Deslandes et al., 2009). Furthermore, some
TLCs—for example, exercise, diet, and meditation—may
also be neuroprotective and reduce the risk of subsequent
age-related cognitive losses and corresponding neural
shrinkage (Hamer & Chida, 2009; Pagnoni & Cekic, 2007;
Raji et al., 2010). Many TLCs—such as meditation, relax-
ation, recreation, and time in nature—are enjoyable and
may therefore become healthy self-sustaining habits (Di-
donna, 2009).
Many TLCs not only reduce psychopathology but can
also enhance health and well-being. For example, medita-
tion can be therapeutic for multiple psychological and
psychosomatic disorders (Chiesa, 2009; Didonna, 2009;
Shapiro & Carlson, 2009). Yet it can also enhance psycho-
logical well-being and maturity in normal populations and
can be used to cultivate qualities that are of particular value
to clinicians, such as calmness, empathy, and self-actual-
ization (Shapiro & Carlson, 2009; Walsh, 2011; Walsh &
Shapiro, 2006).
Knowledge of TLCs can benefit clinicians in several
ways. Utilizing TLCs may result in greater clinical flexi-
bility and effectiveness and less role strain. It will be
particularly interesting to see the extent to which clinicians
exposed to information about TLCs adopt healthier life-
styles themselves and, if so, how adopting them affects
their professional practice, because there is already evi-
dence that therapists with healthy lifestyles are more likely
to suggest lifestyle changes to their patients (McEntee &
Halgin, 1996). There are also entrepreneurial opportunities.
Clinics are needed that offer systematic lifestyle programs
for mental health that are similar to current programs for
reversing coronary artery disease (Pischke et al., 2008).
For societies, TLCs may offer significant community
and economic advantages. Economic benefits can accrue
from reducing the costs of lifestyle-related disorders such
as obesity, which alone accounts for over $100 billion in
costs in the United States each year (World Health Orga-
nization, 2008). Community benefits can occur both di-
rectly through enhanced personal relationships and service
(Post, 2007) and indirectly through social networks.
Recent research demonstrates that healthy behaviors
and happiness can spread extensively through social net-
works, even through three degrees of separation to, for
example, the friends of one’s friends’ friends (J. H. Fowler
& Christakis, 2008, 2010). Encouraging TLCs in patients
may therefore inspire similar healthy behaviors and greater
well-being in their families, friends, and co-workers and
thereby have far-reaching multiplier effects (Christakis,
2009; J. H. Fowler & Christakis, 2010). These effects offer
novel evidence for the public health benefits of mental
health interventions in general and of TLCs in particular.
So what lifestyle changes warrant consideration? Con-
siderable research and clinical evidence support the follow-
ing eight TLCs: exercise, nutrition and diet, time in nature,
relationships, recreation, relaxation and stress manage-
ment, religious and spiritual involvement, and contribution
and service to others.
Exercise
Exercise offers physical benefits that extend over multiple
body systems. It reduces the risk of multiple disorders,
including cancer, and is therapeutic for physical disorders
ranging from cardiovascular diseases to diabetes to prostate
cancer (Khaw et al., 2008; Ornish et al., 2008). Exercise is
also, as the Harvard Mental Health Letter (“Therapeutic
Effects,” 2000, p. 5) concluded, “a healthful, inexpensive,
and insufficiently used treatment for a variety of psychiatric
disorders.”
As with physical effects, exercise offers both preven-
tive and therapeutic psychological benefits. In terms of
Roger Walsh
580 October 2011
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American Psychologist
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prevention, both cross-sectional and prospective studies
show that exercise can reduce the risk of depression as well
as neurodegenerative disorders such as age-related cogni-
tive decline, Alzheimer’s disease, and Parkinson’s disease
(Hamer & Chida, 2009; Sui et al., 2009). In terms of
therapeutic benefits, responsive disorders include depres-
sion, anxiety, eating, addictive, and body dysmorphic dis-
orders. Exercise also reduces chronic pain, age-related cog-
nitive decline, the severity of Alzheimer’s disease, and
some symptoms of schizophrenia (Colcombe & Kramer,
2003; Daley, 2002; Deslandes et al., 2009; Stathopoulou,
Powers, Berry, Smits, & Otto, 2006).
The most studied disorder in relation to exercise to
date is mild to moderate depression. Cross-sectional, pro-
spective, and meta-analytic studies suggest that exercise is
both preventive and therapeutic, and in terms of therapeutic
benefits it compares favorably with pharmacotherapy and
psychotherapy (Dowd et al., 2004; Sidhu et al., 2009). Both
aerobic exercise and nonaerobic weight training are effec-
tive for both short-term interventions and long-term main-
tenance, and there appears to be a dose–response relation-
ship, with higher intensity workouts being more effective.
Exercise is a valuable adjunct to pharmacotherapy, and
special populations such as postpartum mothers, the el-
derly, and perhaps children appear to benefit (Hamer &
Chida, 2008; Larun, Nordeim, Ekeland, Hagen, & Heian,
2006; Sidhu et al., 2009).
Possible mediating factors that contribute to these
antidepressant effects span physiological, psychological,
and neural domains. Proposed physiological mediators in-
clude changes in serotonin metabolism, improved sleep, as
well as endorphin release and consequent “runner’s high”
(Deslandes et al., 2009; Stathopoulou et al., 2006). Psycho-
logical factors include enhanced self-efficacy and self-
esteem, interruption of negative thoughts and rumination
(Dowd et al., 2004), and perhaps the breakdown of mus-
cular armor, the chronic psychosomatic muscle tension
patterns that express emotional conflicts and are a focus of
somatic therapies (Smith, 2000).
Neural factors are especially intriguing. Exercise in-
creases brain volume (both gray and white matter), vascu-
larization, blood flow, and functional measures (Erickson
& Kramer, 2009; Hamer & Chida, 2009). Animal studies
suggest that exercise-induced changes in the hippocampus
include increased neuronogenesis, synaptogenesis, neuro-
nal preservation, interneuronal connections, and BDNF
(brain-derived neurotrophic factor, the same neurotrophic
factor that antidepressants upregulate) (Cotman & Berch-
told, 2002).
Given these neural effects, it is not surprising that
exercise can also confer significant cognitive benefits (Mc-
Morris et al., 2009). These range from enhancing academic
performance in youth, to aiding stroke recovery, to reduc-
ing age-related memory loss and the risk of both Alzhei-
mer’s and non-Alzheimer’s dementia in the elderly (Hamer
& Chida, 2009; Quaney et al., 2009). Multiple studies show
that exercise is a valuable therapy for Alzheimer’s patients
that can improve intellectual capacities, social functions,
emotional states, and caregiver distress (Christofoletti,
Oliani, Gobbi, & Stella, 2007; Deslandes et al., 2009).
Meta-analytic studies provide more fine-grained de-
tails about the cognitive benefits of exercise for the elderly
and offer four kinds of good news. First, the effects can be
large, reducing the risk of Alzheimer’s disease by 45% and
increasing cognitive performance by 0.5 SD (Hamer &
Chida, 2009). Second, though women may gain more than
men, everyone seems to benefit, including both clinical and
nonclinical populations. Third, improvements extend over
several kinds of psychological functions, ranging from
processing speed to executive functions. Fourth, executive
functions, such as coordination and planning, appear to
benefit most, a welcome finding given that executive func-
tions are so important, and that both they and the brain
areas that underlie them are particularly age sensitive (Col-
combe & Kramer, 2003; Erickson & Kramer, 2009).
Finally, meta-analyses reveal the specific elements of
exercise that benefit cognition. Relatively short programs
of one to three months in length offer significant benefits,
though programs of six months or longer are more benefi-
cial. There seems to be a threshold effect for session
duration, because sessions shorter than 30 minutes—while
valuable for physical health—yield minimal cognitive
gains. Cognitive benefits are enhanced by more strenuous
activity and by combining strength training with aerobics
(Colcombe & Kramer, 2003; Hertzog, Kramer, Wilson, &
Lindenberger, 2009). In short, research validates the words
of the second U.S. president, John Adams, who wrote, “Old
minds are like old horses; you must exercise them if you
wish to keep them in working order” (Hertzog et al., 2009,
p. 26).
Fortunately, even brief counseling can motivate many
patients to exercise (Long et al., 1996), and the risks are
minimal, although an initial medical exam may be war-
ranted. Yet despite the many mental and medical benefits
of exercise, only some 10% of mental health professionals
recommend it. And who are these 10%? Not surprisingly,
they are likely to exercise themselves (McEntee & Halgin,
1996).
Nutrition and Diet
There is now considerable evidence of the importance of
nutrition for mental health, and an extensive review of over
160 studies suggests that dietary factors are so important
that the mental health of nations may be linked to them
(Go´mez-Pinilla, 2008). Given the enormous literature on
this topic, it is easy to feel overwhelmed. Therefore, the
following sections review this complex literature but also
distill easily communicable principles, because such ease
of communication strongly influences whether therapists
recommend and patients adopt such treatments (Duncan,
Miller, Wampold, & Hubble, 2009). Two major dietary
components must be considered: food selection and sup-
plements.
Food Selection
For food selection, the key principles for TLCs are to
emphasize a diet that
581October 2011
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American Psychologist
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1. Consists predominantly of multicolored fruits and
vegetables (a “rainbow diet”).
2. Contains some fish (a “pescovegetarian diet”):
Preference should be given to cold deep-seawater
fish (e.g., salmon), which are high in beneficial
omega-3 fish oils, while avoiding the four species
with high mercury levels (shark, swordfish, king
mackerel, and tilefish) (Oken et al., 2008).
3. Reduces excessive calories: For societies confront-
ing the “globesity” epidemic, reducing excess cal-
ories offers both economic and public health ben-
efits (Delpeuch, Marie, Monnier, & Holdsworth,
2009). For individuals, reducing excess calories
offers medical and neuroprotective benefits (Prolla
& Mattson, 2001). This neuroprotection is espe-
cially important in light of recent findings suggest-
ing that adult obesity may be associated with re-
duced cognitive function, as well as reduced white-
and gray-matter brain volume (Raji et al., 2010;
Wolf et al., 2007). Fortunately, pescovegetarian
diets are low in calories.
Multiple human and animal studies suggest that pescoveg-
etarian diets may prevent or ameliorate psychopathologies
across the life span (Go´mez-Pinilla, 2008; Willis, Shukitt-
Hale, & Joseph, 2009). Such diets may enhance cognitive
and academic performance in children as well as ameliorate
affective and schizophrenic disorders in adults. They also
offer neuroprotective benefits, as demonstrated by reduc-
tions in the incidence of age-related cognitive decline,
Alzheimer’s disease, and Parkinson’s disease (Go´mez-
Pinilla, 2008; Kang, Ascherio, & Groodstein, 2005; Morris,
Evans, Tangney, Bienias, & Wilson, 2006). Several studies
of the Mediterranean diet—including a meta-analysis of 12
prospective studies with over 1.5 million subjects—found
reductions in the incidence of both Alzheimer’s and Par-
kinson’s diseases (Sofi, Cesari, Abbate, Gensini, & Casini,
2008). Dietary elements that appear to be particularly neu-
roprotective include fish, vegetables, and perhaps fruit, as
well as lower intake of animal fats (Gu, Nieves, Stern,
Luchsinger, & Scarmeas, 2010; Kang et al., 2005; Morris et
al., 2006). Of enormous public health importance are recent
findings suggesting that, owing to epigenetic factors, “the
effects of diet on mental health can be transmitted across
generations” (Go´mez-Pinilla, 2008, p. 575).
Supplements
Growing evidence suggests that food supplements offer
valuable prophylactic and therapeutic benefits for mental
health. Research is particularly being directed to Vitamin
D, folic acid, SAME (S-adenosyl-methionine), and—most
of all—fish oil (Sarris, Schoendorfer, & Kavanagh, 2009).
Fish and fish oil are especially important for mental
health. They supply essential omega-3 fatty acids, espe-
cially EPA (eicosapentaenoic acid) and DHA (docosa-
hexaenoic acid), which are essential to neural function.
Systemically, omega-3s are anti-inflammatory, counteract
the pro-inflamatory effects of omega-6 fatty acids, and are
protective of multiple body systems. Unfortunately, mod-
ern diets are often high in omega-6s and deficient in omega-3s
(Freeman et al., 2006).
Is this dietary deficiency associated with psychopa-
thology? Both epidemiological and clinical evidence sug-
gest that it is. Affective disorders have been the ones most
closely studied, and epidemiological studies, both within
and between countries, suggest that lower fish consumption
is associated with significantly, sometimes dramatically,
higher prevalence rates of these disorders (Freeman et al.,
2006; Noaghiul & Hibbeln, 2003). Likewise, lower omega-3
levels in tissue are correlated with greater symptom sever-
ity in both affective and schizophrenic disorders, a finding
consistent with emerging evidence that inflammation may
play a role in these disorders (Amminger et al., 2010).
However, epidemiological studies of dementia and omega-3
fatty acid intake are as yet inconclusive (Freeman et al., 2006).
Epidemiological, cross-sectional, and clinical studies
suggest that omega-3 fatty acid supplementation may be
therapeutic for several disorders. Again, depression has
been the disorder most closely studied (Stahl, Begg, Weis-
inger, & Sinclair, 2008). Several meta-analyses suggest
that supplementation may be effective for unipolar, bipolar,
and perinatal depressive disorders as an adjunctive, and
perhaps even as a stand-alone, treatment (Appleton, Rog-
ers, & Ness, 2010; Lin & Su, 2007), although at this stage,
supplementation is probably best used adjunctively. Ques-
tions remain about optimal DHA and EPA doses and ratios,
although one meta-analysis found a significant correlation
between dose and treatment effect, and a dose of 1,000 mg
of EPA daily is often mentioned, which requires several
fish oil capsules (Freeman et al., 2006; Kraguljac et al.,
2009).
There are also cognitive benefits of supplementation.
In infants, both maternal intake and feeding formula sup-
plementation enhance children’s subsequent cognitive per-
formance (Freeman et al., 2006; Go´mez-Pinilla, 2008; In-
nis, 2009). In older adults, fish and fish oil supplements
appear to reduce cognitive decline but do not seem effec-
tive in treating Alzheimer’s disease (Fotuhi, Mohassel, &
Yaffe, 2009).
The evidence on omega-3s for the treatment of other
disorders is promising but less conclusive. Supplementa-
tion may benefit those with schizophrenia and Huntington’s
disease as well as those exhibiting aggression in both
normal and prison populations. In children, omega-3s may
reduce aggression and symptoms of attention-deficit/hy-
peractivity disorder (ADHD; Freeman et al., 2006; Song &
Zhao, 2007).
A particularly important finding is that fish oils may
prevent progression to first episode psychosis in high-risk
youth. A randomized, double-blind, placebo-controlled
study was conducted of 81 youths between 13 and 25 years
of age who had subthreshold psychosis. Administering fish
oil with 1.2 g of omega-3s once per day for 12 weeks
reduced both positive and negative symptoms as well as the
risk of progression to full psychosis. This risk was 27.5%
in controls but fell to only 4.9% in treated subjects. Par-
ticularly important was the finding that benefits persisted
during the nine months of follow-up after treatment cessa-
582 October 2011
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American Psychologist
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.