Lifestyle medicine interventions help pediatricians manage adolescent depression

With the rising prevalence of depression in adolescents, screening requirements are increasingly falling on pediatric primary care providers, who are encountering more at-risk patients. A new literature review in the Harvard Review of Psychiatry underscores the evidence that non-traditional, so-called lifestyle interventions can help providers meet the growing need for youth depression management. The journal is published in the Lippincott portfolio by Wolters Kluwer.

The article reviews studies of lifestyle medicine interventions related to physical activity, sleep, nutrition, substance use, social connectedness, and stress management and provides clinical practice recommendations.

"Having additional and more comprehensive details about such lifestyle recommendations could help clinicians integrate specific advice into anticipatory guidance, management, and treatment plans," suggest Talia S. Benheim, BA, and her colleagues at Massachusetts General Hospital, along with Michelle Dalal, MD, of the University of Massachusetts Chan Medical School and Daniel Hosker, MD, in the September/October issue of the Harvard Review of Psychiatry.

Lifestyle medicine interventions can mitigate lack of access to traditional mental health treatments.

Adolescent depression is strongly associated with negative academic, employment, and health outcomes well into adulthood, and studies point to the importance of early and timely access to mental health interventions. Yet, inaccessibility of mental health services persists, especially among marginalized populations.

The utility, versatility, and cost-effectiveness of lifestyle interventions are well known. They can be used by both licensed and non-licensed providers; implemented in a standalone manner or as part of a larger treatment plan; administered in-person or virtually, with a single patient or in groups; and are often more cost-effective and accommodating to patients' unique cultural situations.

The article reviews evidence of lifestyle interventions in physical activity, sleep, nutrition, substance use, social connectedness, and stress, demonstrating efficacy or feasibility in reducing depressive symptoms in adolescents. Studies included clinical trials, quantitative studies, and qualitative studies, as well as the authors' own clinical experience.

Regardless of whether physical activity is considered light or rigorous, many studies demonstrate the efficacy of physical activity in reducing depression symptoms. For example, one revealed that a two-hour decrease in sedentary activity in patients between ages 12 and 16 reduced depression scores by 16%–22% by age 18.

Sleep problems in adolescents persist into adulthood and have been associated with lack of response to depressive treatment and are even a risk factor for suicide. Yet, one study demonstrated that simple and specific guidelines for healthy sleep habits improved depressive symptoms. Bedtime routines such as keeping a diary or maintaining wind-down activities, as well as cognitive-behavioral therapy for insomnia, are also important.

Nutritional studies demonstrate that healthy plant- and whole food–based diets can alleviate or reduce depressive symptoms. The authors suggest a number of simple interventional approaches, such as tip sheets or recipes, engaging professional nutritionists, and guidance on so-called mindful or intuitive eating.

Cannabis, alcohol, and nicotine are also associated with depression in adolescents and can hinder effective treatment of both. Studies show prompt intervention is paramount. An online program in Australia has shown that increased knowledge of substances, depression, and anxiety reduced likelihood of drinking.

In adolescents, loneliness is correlated with depression, and lack of social connectedness is a predictor of suicidal ideation. One study revealed that increases in connectedness over time had corresponding reductions in adolescents' suicidal ideation. Numerous forms of connectedness—for example, via extracurricular activities such as clubs and sports—have proven to reduce depressive symptoms and can overlap with other lifestyle interventions.

Finally, interventions to support patients in coping with and managing stress can favorably influence the onset, maintenance, and severity of depression. Successful interventions include deep breathing, meditation, muscle relaxation techniques, and mindfulness-based cognitive therapy.

The authors caution that interventions involving significant behavioral changes can be difficult, especially without social, financial, or cultural support. Despite the scarcity of randomized controlled trials of psychological and health behavior (e.g., physical activity) promoting interventions, Benheim, Dalal, and colleagues believe these interventions can help meet the increasing need for mental health services and give teens and families opportunities to empower themselves with the knowledge, skills, and habits to combat depression.