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REPLAY: Lifestyle Psychiatry: Supporting Mental Health with Dr. Adrian Lopresti and Dr. Joseph Firth

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REPLAY: Lifestyle Psychiatry: Supporting Mental Health with Dr. Adrian Lopresti and Dr. Joseph Firth

Dr. Joseph Firth joins our ambassador, Dr. Adrian Lopresti, to discuss the emerging field of lifestyle psychiatry. Adrian and Joseph discuss the importance of engaging specialists to support patients with lifestyle interventions, such as exercise physiologists and nutritionists, as a means to increase the health outcomes of the patient.  

Joseph shares his work on the use of digital technology to support mental health patients to comply with lifestyle psychiatric prescriptions, including the use of smart phone apps for exercise, nutrition, sleep and smoking cessation. Nutrition and nutritional supplementation for the benefit to mental health conditions is discussed as part of a conversation on the role of inflammation in mental health conditions. Joseph shares the importance of connection and community for the individual when engaging with lifestyle psychiatry interventions for lasting benefit to the patient and we finish off the podcast with a discussion into the influence both screen time and social media has on mental health. 

Covered in this episode

[01:05] Welcoming Dr. Joseph Firth
[02:05] Defining lifestyle psychiatry 
[05:10] Increasing the effectivity of nutritional and exercise interventions
[08:37] How Joseph’s implements exercise interventions in this own research
[10:19] Using digital technology in health interventions 
[16:18] Expanding the research to additional populations
[17:56] Apps for health
[21:00] Omega-3s in treatment of mental health conditions
[28:36] screen time and social media and the effects on mental health
[32:20] The relationship between grip strength and mental health
[36:35] Thanking Joseph and final remarks

Key takeaways 

  • Lifestyle psychiatry takes the principles of lifestyle medicine and applies them to the field of psychiatry for the treatment of mental health conditions. It may involve exercise, nutrition, sleep, nutrient supplementation and mindfulness.  
  • Lifestyle psychiatry interventions are most successful when delivered in a collaborative care model with specialists from each modality working with the patient. 
  • Research into the use of digital technology to support mental health patients with lifestyle interventions is underway. Apps can benefit patients of all ages with exercise programs, smoking cessation and dietary interventions. 
  • Early intervention with lifestyle psychiatry for patients with mental health conditions can help to prevent a reduction in the patients’ physical and psychological health over time. 
  • Social connection through lifestyle interventions support engagement and compliance over the longer term. 
  • At present, the UK based Smoke Free AppSleepio, and the Nike Fitness apps offer support to the patient and are well regarded. 
  • There is considerable evidence for the use of targeted nutrient supplementation for mental health conditions and this is a field that is continually developing. Clarity on which specific nutrients supports a mental health condition is still an area for continued research to ensure targeted treatment. There are, however, more studies into supplementation than dietary interventions. 
  • Anti-inflammatory therapeutics may support a reduction in depression in patients with high inflammation. 
  • Screen time and social media use are areas that may influence mental health outcomes for patients, with connections to the sedentary behaviour associated with screen time and reduced exercise. Research suggests that social media may interfere with cognition, brain development and mental health. 

Resources discussed by Dr. Firth

Dr. Joseph Firth
Smoke Free App
Sleepio App
Nike Training Club App

Additional resources and further reading

Lifestyle Psychiatry 

Dr Joe Firth interview with Blackmores Institute (2018)
Article: Introducing Lifestyle Psychiatry: Principles, evidence and implementation of health behaviours in mental healthcare
Research: A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (Firth, et al, 2020)
Article: Five lifestyle changes to enhance your mood and mental health (Firth, 2018)
Article: Toward preventative psychiatry: the role of advanced epidemiological methods’ (Firth, Wootton & Carvalho, 2020)

Nutrients for mental health 

Article: Nutrients improve first-episode psychosis (Blackmores Institute, 2018)
Research: International Society for Nutritional Psychiatry Research Practice Guidelines for Omega-3 Fatty Acids in the Treatment of Major Depressive Disorder (Guu, et al., 2019)
Research: Food and mood: how do diet and nutrition affect mental wellbeing? (Firth, et al., 2020)

Screen use and mental health 

Article: Can smartphones help depression? (Blackmores Institute, 2018)
Article: Schizophrenia and smartphones: Separating speculation from science’ (Torous & Firth, 2015)
Research: The online brain: how the internet may be changing our cognition (Frith, et al., 2019)

Handgrip and mental health 

Handgrip can predict cognitive health (Blackmores Institute, 2018)

Activity for mental health 

Article: Dr Joseph Firth: Music can be powerful for your workouts (Record Union, 2020)
Podcast: Joseph Firth: The role of exercise and nutrition in early psychosis (Mad in Amercia podcast, 2022)
Video: Staying active to support mental health and wellbeing during COVID-19' Harvard New


Adrian: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. FX Medicine acknowledges the traditional custodians of country throughout Australia, where we live and work, and their connections to land, sea, and community. We pay our respect to the elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander people today. 

With us today is Dr. Joseph Firth, UK Research and Innovation Future Leaders Fellow at the University of Manchester. Dr. Firth completed his PhD at the University of Manchester, and has a bachelor's degree in psychology.

He has published more than 200 peer-reviewed articles in international research journals, including some of the top-ranked medical journals in the world. Dr. Firth has a strong interest in health behaviours, such as physical activity, diet, and sleep, and its relationship to mental illness and brain health. In addition to this, he's undertaking research, examining how digital technology can influence mental health, and these are some of the topics we'll be discussing with him today.

Welcome to FX Medicine, Joe. Thanks for being with us today.

Joseph: Thank you for having me. It's a pleasure to be here.

Adrian: I know that certainly for me, the importance of health behaviours such as what we eat, and how we sleep, and how physically active we are, and our social connections on our mental health is an area that I'm personally very passionate about. But unfortunately, some of these behaviours are often overlooked when we treat children and adults presenting with mental health problems, such as depression and anxiety. And your published works on lifestyle psychiatry have shown just how important these behaviours are. But firstly, can you clarify what is lifestyle psychiatry?

Joseph: Well, yes. Lifestyle psychiatry, I think is quite a new term that can mean different things to different researchers and different clinical people and academics. But basically, the idea is taking the principles of lifestyle medicine, which is a much longer standing field, is a broad range of different evidences against different health conditions and looking at how the evidence from lifestyle medicine can also apply to psychiatry and the treatment of mental health conditions beyond just physical health conditions. 

So, typically, it always involves the traditional health behaviours, like exercise, nutrition, sleeping, and things like that and how they relate to people's mental health. But then some people include other stuff in the umbrella term of lifestyle. It could include things like nutrient supplementation, it could include things like mindfulness, or others like holistic therapy. So, the term can be quite broad, but it usually includes those core health behaviours as well.

Adrian: Yeah. So certainly like the diet, the exercise, the sleep. I know that they're the integral parts. And then I know there's obviously research on smoking and even screen time, which actually, I wanted to talk about later in terms of screen time and technology. So, who's using lifestyle psychiatry as a treatment approach?

Joseph: Yeah. I think the acknowledgement that health behaviours impact on mental health as much as physical health is quite broad across most clinicians that I interact with. Mental health nurses, psychiatrists and psychologists, are all quite okay with the idea of things like exercise and nutrition being important for mental health and important for the physical health for people with mental illness. 

But unfortunately, lifestyle psychiatry or lifestyle medicine is not well integrated into the mental health services. So, even though often the clinicians working in the services and even the patients being treated, and the families, and everybody kind of acknowledges that these things are important, they're not well integrated. The implementation of, I would say ‘change interventions’ or lifestyle medicine in actual mental healthcare, is sadly under-utilised at the moment. So, as much as we have all the evidence showing that lifestyle can make a difference, it's not widely used in the care services yet.

Adrian: Yeah. I mean, that's certainly the case. I know that we're becoming more aware of the importance of diet, and exercise, and sleep, but the key is trying to work out how to integrate it into current treatment models. And I know that you are in the UK, so do you know whether mental health practitioners like your standard psychiatrists, do you know whether they're using dietary recommendations? Are they prescribing exercises or treatment? Do you know whether that's happening yet?

Joseph: Yeah. A lot of them would do, I'd say, and with the context of our trials we get a lot of support when we're doing the studies on the different lifestyle interventions. They always, is well accepted and well referred to by the psychiatrists. 

But the thing is, the mental health services in the UK are some of the most overstretched and under-resourced services in day-to-day care. Even those who are passionate about lifestyle medicine have very little time, capacity, and resources to actually deliver any type of…beyond just recommending healthy diet and recommending exercise, which we know doesn't really make much of a difference to people's behaviours. There's no real resources in place to actually help the mental healthcare staff across all the different levels to actually refer to a program that works or to actually deliver a lifestyle intervention on a scale that would be needed to make serious change. So, even those who are proponents of it even struggle to actually get it going on the scale that it needs to be.

Adrian: So what about like when you do your research studies, who's the people implementing the actual treatments? Are they nurses, or what background are they?

Joseph: Well, generally, there's two things really. Number one is that we've found from the evidence, a lot of masters are around the exercise stuff really, and the fitness stuff. And when you look at the evidence around that, we've found that the actual fitness and exercise recommendations or interventions are better received and better adhered to when we use fitness staff. 

It kind of sounds obvious, but when we use people from a fitness or exercise background to actually deliver the intervention, rather than expecting the mental health staff to be responsible for delivering the exercise and fitness interventions. That is better than nothing, obviously, but far better than that is being able to actually include these fitness and exercise professionals. 

Like we have therapists for other aspects, occupational therapists in mental healthcare services, or talking therapists, of we can include fitness therapists and physical therapists, the interventions delivered by those people are far superior. And the same with other things like nutritional counselling would compare obviously, from a dietician, then trying to up-skill mental health staff. It's nice if you can do that, but there's a number of problems around expecting that to continue with the demands of clinical case load, and then also just the statements today on the evidence and the motivation to actually deliver the interventions is much higher in people with proper skills and from those backgrounds. 

So, we are always trying to include these physical health practitioners for whatever intervention we're trying to increase the use of. We try to include those in the mental healthcare services as a member of staff, or at least as a point of referral, such that they can deliver a really interesting intervention that gets people going and keeps the patients involved, rather than just saying, "Oh, you should be exercising a bit more, or should you be eating a bit better?" Like everybody has been told a million times and doesn't make any difference. If you get these guys in there who are actually passionate about it and really skilful and that's their profession, as you can imagine, it goes a lot better.

Adrian: Yeah. So with the research that you've done, is there a specific area that you've mainly done your research on? Is it exercise? Is it dietary interventions? Is it nutraceuticals? Where's your research mainly been focused on?

Joseph: The vast majority of my actual clinical research has been focused around exercise intervention in two ways.

Adrian: Exercise.

Joseph: Number one, setting up exercise staff, actually, in mental healthcare units. So like exercise classes and fitness staff on site for people in mental health rehabilitation. And then number two, setting up exercise referral schemes, basically, where people get referred from the mental health services to their local community leisure centres, where there is fitness staff on hand, but where also mental health champions connected with the services receive those referrals and get people into exercise. 

And number three now, what we're doing now is the whole program of work around how we can make use of digital technologies in order to increase the availability of lifestyle interventions in mental healthcare. So we're setting up a number of things around smoking cessation, online support stuff through apps for smoking cessation. We're going to be doing some diet and nutrition stuff And right now we're setting up a home fitness stuff that can be offered through the early intervention services for young people. It's a live fitness class by a trainer who works within the service dedicated for the youth mental health services. And people can just log in from home, do their Zoom fitness session, do a lifestyle Q&A with the fitness providers over areas of lifestyle, what they should be eating, how they can stay active on a day-to-day basis. 

So it's like a brief fitness thing that people can join in with on a regular basis. And then also get some personalised feedback and discussion around the lifestyle in a small group setting, because we've found that would be quite popular. So, really just making use of all this new digital tech to make lifestyle stuff a little bit more available in a very cost-friendly way across the mental health services.

Adrian: And when you say you're digital, so what's happening there? Is it a specific program that you're offering through the digital technology, or is that what's happening?

Joseph: Yeah. It will be. We've been testing out a number of different approaches with the service users, with the patients from the youth mental health services. And we've settled on one already for this market. We have a trial underway. And what people really like from the digital stuff is the sense of connection. Digital technologies by themselves are good and they can give people a lot of detailed feedback and advice, but really what the people, well,  we've spoke to in the mental health services did really value, is the ones that really bring people together, make use of digital technologies to form real people connections. 

So, the smoking app that we're using for an active trial, which was by far the most popular that we looked at, was the Smoke Free app, which is in the UK. And basically can connect people to live smoking support at any time of the day, and also do smoking clinics, which is just like a group setting for smoking cessation counselling, and it can give people…you know, if someone is having a craving or having a tough time, it can connect people to an actual smoking support advisor, a 24/7 real person, not a robot who can advise them.

Adrian: Oh, wow.

Joseph: So, that seems to be very popular, but our trial is currently underway, so we don't know the results of that. And then same for the exercise stuff, tested out a number of different exercise apps which people mostly liked the technologies of, and appreciated the capabilities of. But we feel the alternative of actually just using an online group, using like a Zoom, like a fitness session thing that can be delivered remotely, seemed to be more popular in terms of people actually wanting to do it on a regular basis and bringing people together in that group setting. So, we're just setting up the trial for that now. We've done a few practice sessions and stuff that's gone quite well.

Adrian: So, it's like a live exercise session? So somebody is doing, say, an aerobics class and people are kind of...at a particular time, and then people are kind of logging in and doing the class together? Is that what's happening?

Joseph: Yeah. Exactly. So, it's going to be twice weekly. But then it gets recorded as well, so people can watch back the recording if they happen to miss it. 
And then there's some basic equipment involved. Everybody who's participating in the study gets just a band, which are super cheap to buy, but you can do a lot of different exercises with these resistance bands. So, we can post those out to people. And then we do the fitness stuff nice and steady, but quite upbeat. And then we do the...like give the people the opportunity for a question and answer session afterwards where they can just discuss other aspects of healthy living and lifestyle with the fitness trainers and with the group as well. What's been working for people just to make it feel like a cohort going through this fitness stuff together. So, we're hoping...obviously, the study is literally in the setup phases for that, so we don't know how it goes, but we're hoping it'll go quite well. We've seen it work in other contexts. 

Adrian: You also did the same with the smoking interventions? You did that through digital technology too?

Joseph: Yeah. We've got an active trial in that area, after settling on the Smoke Free app, we're looking at how people if they actually do use it in the context of the trial, which aspects of the app people use the most. And then also, obviously, if it helps them quit smoking, and then we check people's physical and mental health, just self-report before and after participating as well, just to see if it's having any significant effects on people's psychological well-being. So…

Adrian:  And these exercise and smoking interventions, are they done with people with any particular mental health problem?

Joseph: Yeah. Most of my research now, in terms of the clinical research bit, is done through the early intervention services. So, quite a broad, but also quite a specific group of young people aged between say, 14 to 35. So, it's kind of like adolescents to young adults, being treated for psychotic disorders most of the time. But it's important to do a lot of research on that group because it's in the early phases of the treatment for mental health conditions when we see the biggest decline in people's physical health. Usually, unfortunately, even in the early intervention services, by the time people have been treated there, they've been psychologically unwell for a long time, but their physical health is relatively intact. Whereas after years of struggling with a severe mental health condition and also even the medications themselves, people's physical health goes really downhill to the point where it can be even difficult to expect them to be engaging with things like fitness interventions or changing the diet and stuff after a long time. So, it's important to try and reach people as early as possible in the course of mental health treatment in order to improve physical health outcomes. 

For sure, I mean, young people, you can usually get a little bit more motivation for the fitness stuff and a little bit high levels of baseline fitness, which makes it easier to get things going. Not that it's not important to help people later on in their later phases of illness, for sure, those are the guys who are more immediate at risk from really severe physical health conditions, but it just happens to be the focus of my own research to use the early intervention approach.

Adrian: And so you don't have any results yet?

Joseph: Not from the digital stuff. Literally just that we got a big grant from the UKRI, just before the pandemic kicked off. And then we've just been in the setup phases. It's for the fitness one, just going through the ethics and everything now, and then we're going to be doing some diet and nutrition things. 

In the meantime, what we've been doing before we can actually do the formal research, is getting the feedback, engaging the patients and the clinicians and seeing what actually young people with mental health conditions actually want from digital interventions. So, we've run a massive perspective gathering exercise online, got different opinions from about 600 young people, showing them different types of demo technologies and things like that, and seeing what they think, because ultimately, we want something that can really be actually implemented in mental healthcare. So, a lot of the discussions are around what will people actually continue to use? To the clinicians, what will you guys be comfortable recommending? What do you guys think can actually continue to be integrated in day-to-day clinical care? It's easier for us to just use the funding to set up a trial and just pay people to participate and make it all really smooth and get a nice study running, but then ultimately that's pointless if as soon as the study ends, then the intervention dies away. 

Adrian: Yeah, that’s fascinating. So, it's just really then looking at delivering the lifestyle components through digital technology, and obviously, you're looking at young people, but it'd be interesting to see how it would be kind of taken up by older age people. Any plans to do some research with that population?

Joseph: Yeah, for sure. We're starting with the younger group, and that's where we've received the grant funding to do these initial experiments. And even right now, while we've been setting up these studies, the first questions we've been asked by the clinical teams who are helping us deliver these trials, have been, "Oh, can we offer this to our older groups? Can we offer this through the community mental health teams? Can we do this with it?" Already people are thinking of other ways to use these technologies. When we show them around it, it's well received and they're wanting already to start off in it through the wider group. So, I could imagine how it would grow. 

Adrian: You know, the fact that you said that delivering it live. So, I wonder whether that's that social connections component, that social support component which is also important with regards to any digital or any intervention that we do. So, it's interesting that you run it that way.

Joseph: Yeah. I think so, Adrian. We've noticed that in the past there's the stuff that can kind of connect people to other people for lifestyle interventions just makes people a lot more interested and a lot more open to doing it long-term. People might like the idea of the more isolated interventions but the actual execution and the adherence over time goes so much better if people feel like a part of a group or even just a connection to an individual coach. Just having other people involved makes people much more likely to stick at it over time, and actually enjoy doing it as well, which is a big thing.

Adrian: Yeah. Are there any apps that are out there at the moment that may not have been researched, but anything that you think is useful that if any practitioners that are listening today might be interested in using with their clients? 

Joseph: Yeah. Well, we looked at a lot of different ones and we've been obviously testing them out. And for me, I think the free Nike fitness app is actually really good. And that has different intensities of workouts, different styles actually in the app, and has fitness tracking, gives people individualised feedback on their progress. And the type of feedback we'll get, that's a decent one. We haven't tested it clinically or anything. So, whether the patients would stick at it over time. But it seems to have all the components of what would be a popular app in any context, just because it offers so easy to use and offers such a broad range of different things. I think that's a good one.

Adrian: Any smoking ones?

Joseph: Yeah. The Smoke Free app is the one that we've settled on. That's available freely through our region in the UK, because the actual council have bought like a license for it. But there's a free version of the Smoke Free app that's available for anybody. I think internationally it's just on the app store. And if you have the subscription service, then it gives you access to the 24/7 smoking cessation support, which seems to be a really popular component of smoking apps. 

Adrian: Okay. I'll get the details from you and we'll include it in our show notes so people can have a look at them.

Joseph: Yeah. And also right now we're looking now for apps and digital methods for actually improving people's nutrition or maybe giving them feedback of access to like where to use digital technologies to help people adopt healthier diets and improve their nutrition as well in the context of mental healthcare. Simple but effective things, and maybe even connect people. And we're still in the looking at the different options available for that, where we've kind of settled on the stuff for the fitness and smoking. So if anybody listening to the podcast has any suggestions, they can get in touch with me for things that we can look at around using these digital technologies for nutritional means in the context of mental healthcare, especially. If there's any ideas out there...we go as broad as possible initially to get feedback from everything that we can find. So, I'm hoping for suggestions from anybody listening or yourself, Adrian.

Adrian: So we'll definitely put it out there, if any of our listeners know of any diet ones or in the process of developing one, we'll link you up with them. That's for sure.

Joseph: Yeah. And sleep as well. There’s the Sleepio one is getting widely used in the NHS. That's probably the best example of digital technologies that have received an uptake by the actual NHS in terms of lifestyle medicine for mental health.

So, that's a fantastic example of how this type of research and how lifestyle medicine can actually become part of mental healthcare in a scalable way. It's been quite uplifting to see it really making a difference.

Adrian: I also wanted to talk a bit about some of the work you've done in the area of kind of nutrients, and you've written some fascinating, or you've been a lead author on some fascinating review papers on nutrients for the treatment of different mental health conditions. Can you tell us a bit about that work?

Joseph: Yeah. The actual body of evidence around nutrient supplementation as an adjunctive treatment for mental illness, is something going back just as long as all the exercise stuff and lifestyle medicine stuff really, that's been like its own field developing in union alongside lifestyle medicine have evolved. And there's in fact a lot more studies and RCTs, especially, around nutrient supplementation in mental health, compared to say dietary interventions, which is interesting to observe. And there's obviously a whole range of different nutrients that have been tested across the broad spectrum of mental health conditions. So, it's a big body of research already.

Adrian: Yeah. And so, with your paper that you published back in 2019, what was the strongest body of evidence in terms of nutrients?

Joseph: Oh yeah, sure. Well, the omega-3 supplementation is the most widely researched, and it therefore also came to the forefront. And from that review as having the strongest evidence available in terms of using adjunctive omega-3s in the treatment of major depression, I believe, and also some other mental health condition there seems to be. 

But even though there's a number of RCTs showing quite positive beneficial effects from omega-3 supplementation, there's also a lot of null trials as well. And there's a lot of misunderstanding or lack of consensus on how the actual mechanisms through which omega-3s can help to reduce depression and improve mental health. Some people think it's a direct result of the omega-3s themselves, just in the body and in the brain. Some people think it could be reducing inflammation. Omega-3s are quite known to be able to reduce inflammation all over, like neurophysiological hormonal pathways. It's an interesting one. And it could explain why there's some variation in the results that we see from studies.

Adrian: Yeah.

Joseph: And if the further research, really rather than just testing omega-3s, could do with trying to figure out what is the actual biological component of omega-3s, or what is the actual conditions. It might be that they work for certain groups of people and not for others. The variation between mental health conditions is so massive even within a specific diagnosis. We probably need to get a more fine-grain understanding of the conditions under which, and for the people which these nutrients can actually be effective before really rolling out on a massive scale, or anything like that, or doing further research just to prove the efficacy. We don't really know all these things yet, despite there being such a big body of research on potential efficacy already indicated. So, yeah, it'd be interesting to see how the research develops in that line as well.

Adrian: Yeah, I agree. I think that's where obviously we're doing work, and even myself, I do clinical trials on people with depression, but we do know that people with depression, that label, it varies so much and some people sleep too much and some people don't sleep enough, and some people's appetite is higher and some people's appetite is lower, and some people present with inflammation and some people don't. So, yeah, I agree. I think the next thing is for us to really identify who it works for and how it works. And we still need a lot more research around that.

So, with the omega-3s, do you know, is it people who are low on omega-3s? Do they do better, or we're not even at that point yet?

Joseph: There's been some recent evidence to indicate the inflammation could actually make a difference. And some trials showing the anti-inflammatory medications obviously, have higher anti-depressant effects on people with high levels of inflammation. So, you could imagine that being, not an easy way to stratify people, but a first step. But then also, like what you said, I fully agree. You have some patients that present with high inflammation and some that don't. And then even within that group, you have some people where the high inflammation seems related to the symptoms, and then some cases where it doesn't. So, it's so confusing.

Adrian: Yeah. Absolutely.

Joseph: And so hard to pin down. But I guess the benefit of things like nutrient supplements and omega-3s, is it's not necessarily like testing out different drugs. And you don't know how it'll interact with those drugs. They are generally perceived to be pretty safe, and widely available, and quite cheap to get a hold of. So if people want to just try omega-3s and things, obviously alongside current medications, it's easier for different people to do so without as much risk, obviously with their doctor's advice, just to make sure it doesn't interact with anything. It's quite easy for people to personalise themselves and see what works and what doesn't work in a simple way, without as much risk as certain medications. 

But for sure, it's just so confusing to try and figure out what are the conditions, or even the ingredients of the omega-3s as well. We have seen in the literature that the ones with the highest levels of EPA and the higher doses of EPA, rather than DHA, obviously the two main components of omega-3 fatty acids, the EPA ones seem to have greater beneficial effects on depressive symptoms as well and greater reductions. And so that could be another thing as well, we're considering the actual constitutions and the quality of the omega-3 being used.

Adrian: So higher EPA, and dosage wise, given the safety profile with omega-3s, higher EPA, is there a dose that generally has greatest efficacy?

Joseph: I think, if I'm trying to remember now from the actual analysis and things, but I think it might be 2000 milligrams per day of the high EPA formulas there were where we saw the best effects. But I'll double-check that with the thesis. It might even be...

Adrian: I think you're right.

Joseph: ...a little bit higher than that.

Adrian: Yeah. I think it was at least 1500, yeah.

Joseph: Some people have like gastrointestinal side effects and things from very high dose EPAs. So, I guess with any dosage strategy before moving up to the upper limit dose, you're better off trialling out a very small amount first. Even in the trials, I think they start with like a titrated dose methodology. So, start people on 500 milligrams a day or something like that. Just check that everybody is getting on okay before moving up to those higher dosage ranges.

Adrian: Yeah. And I think people need to be aware too, that if you're going to use omega-3s, it's not going to work quickly. So, it's something that you can use. I mean, obviously, your research has indicated that as an adjunct treatment, omega-3s have efficacy. So, but for people to just continue taking it over a longer-term rather than four weeks and expect dramatic improvements in their mood, that's not going to happen.

Joseph: Yeah. And there's even other nutrients that are emerging as well. So, I guess different people could benefit from different types of nutrients, it’s not all about omega-3s, there's the Methylfolate, which is the really high dose B vitamin stuff, seems to have positive effects under some conditions, especially in people with low levels of folate, vitamin B9. And also the N-acetyl cysteine and the other antioxidants are also showing some efficacy. Again, in different conditions the effects are sometimes more and the effects are sometimes positive. And the research is really just beginning to try and figure out why is it sometimes working, and why is it sometimes not? So, it'll be interesting to see how the field develops and actually get the more fine grain understanding of how the different nutrients can influence different mental health conditions in different people.

Adrian: All right. So, we've got then, obviously, you've mentioned the lifestyle psychiatry, obviously there's the dietary interventions, there's the exercise, we know that there's a strong link between smoking and mental health, and obviously smoking cessation could be a really important component to any intervention. You've mentioned sleep. There's obviously nutraceuticals that we've kind of mentioned. And I know that your work has mainly been in nutraceuticals. My work has mainly been in the herbal side of things, and there's some different herbal options that people could look at as a component to, I suppose, lifestyle psychiatry too. Have you done much research on things like screen time? Is that your area, you're looking at kind of social media and that type of stuff on mental health?

Joseph: Yeah. We've done a little bit of research around that and particularly around screen time in the context of sedentary behaviour in young people and how that might impact on mental health, there's a whole field of research emerging in that field. And then also around things like social media and just the constant use of online technologies, how that might interact with even cognition and brain development and mental health is another interest of mine. Obviously, we don't really have the long-term research that we do for nutrients or exercise on those type of things, because they've not been around long enough to do enough studies. And then also just the length of time that young people have been exposed to these, we've not seen the long-term effects of things like that either in cohort studies or whatever.

Like we know for instance, exercise reduces the risk of developing depression over this life cost. We haven't actually had a chance to conduct studies that look at how if internet exposure or social media increases or reduces the risk of depression of the life cost, just because nobody's lived out the...there's not the data from the life cost studies yet. So, it'll be interesting to see how that field develops. Already though, there is quite strong evidence that high amounts of screen time, especially in the context of sedentary behaviour is detrimental for physical health and mental health in young people. 

So, you've seen guidelines from like the World Health Organisation trying to be swayed against that and trying to reduce the amount of sedentary screen time that young people are engaging in. I mean, in some ways it's common sense, people say, "Oh, well, obviously." But then in other ways, I'd say that, well, everyone is saying it's obvious, but what is anybody actually doing about it in health policy or in health interventions, public health interventions? Everybody is saying it's so obvious that that's not good for people. Why is there literally almost zero efforts to do anything but other than perpetuate the amount of screen time in young people?

Adrian: Yeah. Exactly.

Joseph: So, it's definitely worth looking at more and really getting to how we can make a difference. So, yeah. I think that's a really interesting area and something that will become increasingly important as we continue to see the wide-scale adoption and basically constant usage of these technologies. And then things like social media, whether they're a force for good or a force for bad in young people.

Adrian: Yeah.

Joseph: A lot of young people with mental illness, even the groups that I work with, report about how social media has had a detrimental effect on their mental health. And that might only apply to the specific individuals, but still for sure, there's a lot of examples of where people have been very seriously affected by the consequences of things that have happened entirely online, but then they've had a really massive impact on their day-to-day mental health and well-being and functioning as well. So, yeah.

Adrian: Yeah. Absolutely.

Joseph: Understanding things like that. But then equally, so far so good, we've seen a lot of interventions now making use of social media to bring people together. So, yeah. Interesting.

Adrian: So it's got a good side and a dark side too, potentially?

Joseph: Yes. Exactly.

Adrian: Now, one thing I wanted to bring up. I recall reading just some of your work on some of the papers you'd authored. Looking at the relationship between grip strength and mental health.

Joseph: Yeah.

Adrian: And so those kinds of research showing that a better grip strength is associated with the reduced risk of suicide, and improved cognition, and greater hippocampal volume. What's going on there?

Joseph: Yeah. So we've done a whole broad range of research, and Miles Imoji clinched my research on the subject, looking at how people with higher levels of maximal grip strength, which is literally just measured using like a hand-grip dynamometer. Most people will have seen these, but they can imagine what it's like, And it's just a thing that you squeeze really hard and it just gives you an output in kilos of how strong your grip is. 
And then when we look at that in the epidemiological studies, we give each person a score, which accounts for other things that make a big difference to grip strength like your age, and your body size, and your gender or sex, things that relate to it. And then like the people's average pound for pound scores, so to speak, really relate to a whole range of mental health outcomes, of physical health outcomes and then also even of brain and cognition outcomes. Now, it's not that grip strength itself is improving people's mental health or cognition. It's not like somebody could...

Adrian: Oh, I just went to the shop and bought one of those hand grip exercises. I thought it was going to increase my brain size. That's not going to happen?

Joseph: Boost your brain up by just getting a really strong grip. You'll probably start breaking...

Adrian: Yeah. Strong forearms.

Joseph: ...people's fingers when you shake people's hands. I don't think that can... It's just that it's a really easy way, having the dynamometer to get an idea of someone's overall muscular fitness, just like we'd use like respiratory tests, or like a basic fitness test to get an idea of somebody's cardiorespiratory fitness. And we already know that cardiorespiratory fitness relates to a range of different physical and mental health outcomes. And we know that by increasing our cardiorespiratory fitness, we can increase our mental health. Obviously, if we increase our physical health, we can increase our brain health, there's a whole body of research looking at all...and even the World Health Organisation recommends that improving cardiorespiratory fitness will improve our mental health and brain health in young people and older people. So, that's widely accepted.

But now this research really about the grip strength stuff, the grip itself is just a marker of someone's overall muscular fitness. So, we've got to think of it in that terms, because of a test of muscular fitness, there's too much influence by people that... So if you get, say you think, "Oh, well, bench press would be a better test of someone's muscular strength." Not necessarily because then the people that do best, just practice most bench press. You know what I mean? So, the other test are kind of too influenced even though it seems like such a small test. It's a good one because it's not too influenced by what people have been practicing, so everyone is used to gripping something quite hard.

And you get an idea from that. So, really, the evidence is signalling that, just as much as improving our cardiorespiratory fitness might be good for our mental health and physical health, equally, improving people's muscular fitness and muscular strength might be really good for mental health and physical health. 

Now, there is some studies emerging, resistance training studies that have not used fitness training, not used cardiorespiratory fitness training, not done cycling, or running the...forgot all of that, and just used weight training. And they have shown some improvement in mental health and physical health. But the body of research is much more nascent compared to obviously, a lot of exercise studies focus on cardio exercises. That's where the evidence really lies. That's what it speaks to at the moment.

But it'd be interesting, we're seeing some strong relationships between muscular strength, even independently of people's fitness that this field can be something that's developed and present new options and new recommendations. So, people don't feel if they hate going for a run, or going for a cycle, they could just easily do some strengthening exercises and get similar benefits for mental health.

Adrian: Oh, okay. I'm a bit disappointed actually, I've got the dynamometer at the office and I did a competition with my son the other day and I beat him. So I told him I must have a bigger hippocampus, a bigger brain than he does. But I won't tell him the truth anymore.

Joseph: Yeah.

Adrian: All right. Well, that's great. I mean, look, thank you very much for all the information that you've given us today. You know, all the important insights into how lifestyle psychiatry can be used to improve current treatments for mental health problems, and how lifestyle psychiatry we need to start thinking about the use of digital technology in terms of how we present it. And maybe that's a new fascinating area of research that you are doing. And then, particularly, we could potentially use it with our clients to help improve outcomes with them and deliver different components. I'm just thinking now, I see clients as a clinical psychologist and I could do the psychology component, but I could potentially get them to do an exercise treatment through some digital technology, which may then be used as an adjunct to the work that I'm doing. So, I'm really looking forward to the research that you're doing and interested in the results when they come out. So, any ideas when you're going to finish?

Joseph: It's actually a seven-year program of research that we've been funded for, because the UKRI are really keen on looking at how we can use digital...we've got to accept that all these digital stuff is here to stay. So, if we can find some good ways for our societies and our mental health services to actually benefit from it, then it's obviously a big positive. So, it's a long program of research, but we'll have results coming out from the preliminary stuff, especially in terms of preferences and what people might like to engage with most, pretty soon. Within the next 12 months, there'll be some papers coming out of our group showing what can be implemented. And like the feasibility stuff will be emerging straight away and then different results across the different health behaviours. First of all, for the smoking stuff, and then for the exercise stuff and nutrition stuff, they'll be coming out all the time, a little bit further down the line. Hopefully, all been well as long as we don't have another shutdown or another pandemic. I'm crossing my fingers that the research can carry on now and everything can move along as planned.

Adrian: Well, I'm certainly looking forward to reading more of your published works in the future. I'm an avid reader of your work, and I recommend for practitioners to certainly check out some of the published works that you've done and some of the brilliant review papers that you've published in very high impact journals, which is brilliant because then that allows it to really kind of reach mainstream psychiatry, which is really important for us in terms of us promoting lifestyle psychiatry. So thank you very much, Joe.

Joseph: Well, thanks a lot, Adrian. That's very kind of you to say. Very nice to hear. And I'm really glad to get some positive feedback on our research. It really does mean a lot when we hear back from clinicians or people promoting the research in the real world, so to speak, because sometimes it can feel like it's just a bit of an echo chamber of academic papers. But then when you hear about it having a positive impact, it's really, really nice indeed. It makes it all seem worthwhile. So thanks for saying that. It means a lot.

Adrian: No, thank you. Keep it up. All right. So, thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr. Adrian Lopresti. And thanks for joining us. We'll see you next time.

About Dr. Joseph Firth

PhD, BSc (Hons) Psyc
Adjunct Research Fellow, Healthy Minds, NICM Health Research Institute

Dr Joseph Firth became a NICM Health Research Institute Adjunct in 2020 upon returning to the United Kingdom. Prior to this appointment, Dr Firth had been a Research Fellow at the Institute since 2017, focused in mental health and clinical research. He was a recipient of the NICM HRI Blackmores Institute Fellowship. Dr Firth is currently a Presidential Fellow (Research) at The University of Manchester in the United Kingdom.

He has published extensively in leading medical journals including The Lancet Psychiatry, World Psychiatry, NeuroImage, JAMA Psychiatry, Schizophrenia Bulletin, and The American Journal of Psychiatry, on the clinical use of exercise and nutritional interventions for improving both physical and mental health outcomes in people with psychiatric conditions.

His ongoing research focuses on developing and evaluating pragmatic and feasible programs aimed at helping young people with mental health problems to engage in regular exercise, and to adopt healthy lifestyles.

In 2017, he completed his MRC-funded PhD in Medicine at The University of Manchester. His PhD research investigated the benefits of physical exercise for young people in the early stages of psychotic disorders. During his PhD, he conducted a range of feasibility studies, qualitative investigations and meta-analyses around exercise for psychosis.

Dr Firth is contacted regularly for expert media commentary on emerging mental health research. His work has been the focus of news stories from key media outlets such as Forbes, The New York Times, CNN, Independent UK, The Times UK, Daily Mail UK, The Australian, Sydney Morning Herald, The Age, The Daily Telegraph, ABC Radio National, ABC online, in addition to televised interviews on BBC News and Sky News.



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