Key publications

Dietary recommendations for the prevention of depression.

Opie RS, Itsiopoulos C, Parletta N, Sanchez-Villegas A, Akbaraly TN, Ruusunen A, Jacka FN.
Nutritional Neurosciences, 2015, DOI: http://dx.doi.org/10.1179/1476830515Y.0000000043

Background: Major depressive disorder is a common, chronic condition that imposes a substantial burden of disability globally. As current treatments are estimated to address only one-third of the disease burden of depressive disorders, there is a need for new approaches to prevent depression or to delay its progression. While in its early stages, converging evidence from laboratory, population research, and clinical trials now suggests that dietary patterns and specific dietary factors may influence the risk for depression. However, largely as a result of the recency of the nutritional psychiatry field, there are currently no dietary recommendations for depression. Aim: The aim of this paper is to provide a set of practical dietary recommendations for the prevention of depression, based on the best available current evidence, in order to inform public health and clinical recommendations.
Results: Five key dietary recommendations for the prevention of depression emerged from current published evidence. These comprise: (1) follow ‘traditional’ dietary patterns, such as the Mediterranean, Norwegian, or Japanese diet; (2) increase consumption of fruits, vegetables, legumes, wholegrain cereals, nuts, and seeds; (3) include a high consumption of foods rich in omega-3 polyunsaturated fatty acids; (4) replace unhealthy foods with wholesome nutritious foods; (5) limit your intake of processed-foods, ‘fast’ foods, commercial bakery goods, and sweets.
Conclusion: Although there are a number of gaps in the scientific literature to date, existing evidence suggests that a combination of healthful dietary practices may reduce the risk of developing depression. It is imperative to remain mindful of any protective effects that are likely to come from the cumulative and synergic effect of nutrients that comprise the whole-diet, rather than from the effects of individual nutrients or single foods. As the body of evidence grows from controlled intervention studies on dietary patterns and depression, these recommendations should be modified accordingly.

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Effectiveness of a Mediterranean diet intervention for improving food intake in people with serious mental illness.

Zarnowiecki D, Wilson A, Bogomolova S, Fielder A, Procter N, O’Dea K, Itsiopoulos C, Strachan J, Ballestrin M, Parletta N.
Journal of Nutrition and Intermediary Metabolism, 2014, 1:27

Background/Aims: People with serious mental illness die 25-30 year sooner than the general population due largely to cardiovascular disease. Lifestyle is a major contributor, including poor diet. Mediterranean-style diets, characterised by high consumption of vegetables, nuts, legumes, olive oil and fish, have been associated with better cardiovascular and mental health. The aim of this study was to evaluate the effectiveness of a Mediterranean diet-based intervention for improving diet in people with serious mental illness.
Methods: A three month pilot feasibility study of the HELFIMED dietary intervention was conducted with 23 residents in a community rehabilitation centre in South Australia. Participants received nutrition education, food hampers, cooking workshops and shopping support based on Mediterranean diet principles. At three months, 20 semi-structured interviews were conducted with participants and support staff to evaluate the intervention. Interviews were transcribed and independently coded for key themes by two researchers.
Results: The framework thematic analysis revealed improvements in participants’ knowledge of and intake of the key elements of Mediterranean diet (fruit and vegetables, olive oil, fish, legumes), reduction in poor nutrition habits (soft drinks, energy drinks, take away meals), as well as the development of independent living skills, including culinary skills such as food preparation and cooking of simple recipes, food shopping and budgeting, healthy meal planning, and social interaction.
Conclusions: A Mediterranean diet-based intervention conducted in a community setting is feasible and achieved positive change in dietary behaviours associated with CVD prevention for participants with serious mental illnesses.

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Association between Mediterranean diet adherence and mental health.

Cho J, Zarnowiecki D, Villani A, Wilson A, Bogomolova S, O’Dea K, Parletta N.
Journal of Nutrition and Intermediary Metabolism, 2014, 1:33

Background/Aims: Depression is a leading cause of disability-adjusted life years, and is predicted to be a top contributor to global burdens of disease by 2030. Emerging evidence suggests that a Mediterranean style diet may be beneficial for improving depression and mental health. The aim of this study was to investigate associations between Mediterranean diet adherence, mental health and quality of life in individuals with depression.
Methods: This study utilised baseline data for 82 adults aged 18-65 years with depression, recruited for a Mediterranean diet intervention. Mediterranean diet adherence was measured using a 14-item questionnaire. Mental health and quality of life were assessed using the Depression Anxiety Stress Scales (DASS), Positive and Negative Affect Scale (PANAS), and Adolescent Quality of Life (AQoL) questionnaire (8D-version). Differences in mental health and quality of life for Mediterranean diet adherence were tested using one-way ANOVA.
Results: Adherence to Mediterranean diet was low, with no participants having a high adherence, 29.6% moderate adherence, and 70.4% low adherence. Lower Mediterranean diet adherence was significantly associated with higher depression (8.08 vs. 12.09, p = 0.042) and anxiety scores (4.92 vs. 8.31, p = 0.014). Conversely, higher scores on the AQoL Happiness (50.78 vs. 34.94, p = 0.006), Coping (52.43 vs. 39.40, p = 0.020) and Mental Health scales (60.60 vs. 48.48, p = 0.005) were significantly associated with higher Mediterranean diet adherence.
Conclusions: This study found that low adherence to a Mediterranean diet was associated with poorer mental health outcomes. This proposes a target for dietary intervention to improve mental health. We are conducting a randomised controlled trial to investigate this.

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Nutritional medicine as mainstream in psychiatry.

Sarris J, Logan AC, Akbaraly TN, Amminger GP, Balanza-Martinez V, Freeman MP, Hibbeln J, Matsuoka Y, Mischoulon D, Mizoue T, Nanri A, Nishi D, Ramsey D, Rucklidge JJ, Sanchez-Villegas A, Scholey A, Su K-P, Jacka JN, on behalf of the International Society for Nutritional Psychiatry Research. The Lancet, 2015, 2(3):271-274

Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefits in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional deficiencies) and mental health, and for the select use of nutrient-based supplements to address deficiencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging field of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.


Nutritional modulation of cognitive function and mental health.

Parletta N*, Milte CM, Meyer B (2013). Invited review, Journal of Nutritional Biochemistry, http://dx.doi.org/10.1016/j.jnutbio.2013.01.002

The important role of diet in cardiometabolic health is generally well recognised; for mental health, it is not so well understood. However, lifestyle risk factors for poor physical health are the same risk factors for mental illness, including poor diet. This is reflected by the high level of poor physical health in people with mental illness. Mediterranean, whole food diets have been associated with reduced risk for chronic disease, but very little research has investigated their mental health benefits. We provide a model for the pathways by which food components provided by a Mediterranean-style diet can facilitate healthy brain function. We then review evidence for the role of selected nutrients/food components – antioxidants, omega-3 fatty acids and B vitamins – in the brain and, hence, modulation of cognitive function and mental health. Converging evidence indicates multiple pathways by which these nutrients can assist in brain function, drawing from studies investigating them in isolation. There is very little work done on synergistic actions of nutrients and whole diets, highlighting a need for human intervention studies investigating benefits of Mediterranean-style diets for mental, as well as cardiometabolic health.

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Effects of omega-3 fatty acids EPA versus DHA on memory and cognitive decline, depressive symptoms and quality of life in older adults with mild cognitive impairment: A 6-month randomised controlled trial.

Sinn N*, Milte C, Street SJ, Buckley JD, Coates AM, Petkov J, Howe PRC (2012).
British Journal of Nutrition, 107:1284-1290.

Depressive symptoms may increase the risk of progressing from mild cognitive impairment (MCI) to dementia. Consumption of n-3 PUFA may alleviate both cognitive decline and depression. The aim of the present study was to investigate the benefits of supplementing a diet with n-3 PUFA, DHA and EPA, for depressive symptoms, quality of life (QOL) and cognition in elderly people with MCI. We conducted a 6-month double-blind, randomised controlled trial. A total of fifty people aged >65 years with MCI were allocated to receive a supplement rich in EPA (1_67 g EPA+0_16 g DHA/d; n 17), DHA (1_55 g DHA+0_40 g EPA/d; n 18) or the n-6 PUFA linoleic acid (LA; 2_2 g/d;n 15). Treatment allocation was by minimisation based on age, sex and depressive symptoms (Geriatric Depression Scale, GDS). Physiological and cognitive assessments, questionnaires and fatty acid composition of erythrocytes were obtained at baseline and 6 months (completers: n 40; EPA n 13, DHA n 16, LA n 11). Compared with the LA group, GDS scores improved in the EPA (P = 0_04) and DHA (P = 0_01) groups and verbal fluency (Initial Letter Fluency) in the DHA group (P = 0_04). Improved GDS scores were correlated with increased DHA plus EPA (r 0_39, P = 0_02). Improved self-reported physical health was associated with increased DHA. There were no treatment effects on other cognitive or QOL parameters. Increased intakes of DHA and EPA benefited mental health in older people with MCI. Increasing n-3 PUFA intakes may reduce depressive symptoms and the risk of progressing to dementia. This needs to be investigated in larger, depressed samples with MCI.

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Oiling the brain: A review of randomised controlled trials of omega-3 fatty acids in psychopathology across the lifespan.

Sinn N*, Milte C, Howe P (2010). Nutrients 2(2):128-170

Around one in four people suffer from mental illness at some stage in their lifetime. There is increasing awareness of the importance of nutrition, particularly omega-3 polyunsaturated fatty acids (n-3 PUFA), for optimal brain development and function. Hence in recent decades, researchers have explored effects of n-3 PUFA on mental health problems over the lifespan, from developmental disorders in childhood, to depression, aggression, and schizophrenia in adulthood, and cognitive decline, dementia and Alzheimer’s disease in late adulthood. This review provides an updated overview of the published and the registered clinical trials that investigate effects of n-3 PUFA supplementation on mental health and behavior, highlighting methodological differences and issues.


Moving towards a population health approach to the primary prevention of common mental disorders.

Jacka FN, Mykletun A, Berk M (2012). BMC Medicine, 10:149 doi:10.1186/1741-7015-10-149

There is a need for the development of effective universal preventive approaches to the common mental disorders, depression and anxiety, at a population level. Poor diet, physical inactivity and smoking have long been recognized as key contributors to the high prevalence noncommunicable diseases. However, there are now an increasing number of studies suggesting that the same modifiable lifestyle behaviors are also risk factors for common mental disorders. In this paper we point to the emerging data regarding lifestyle risk factors for common mental disorders, with a particular focus on and critique of the newest evidence regarding diet quality. On the basis of this most recent evidence, we consequently argue for the inclusion of depression and anxiety in the ranks of the high prevalence noncommunicable diseases influenced by habitual lifestyle practices. We believe that it is both feasible and timely to begin to develop effective, sustainable, population-level prevention initiatives for the common mental illnesses that build on the established and developing approaches to the noncommunicable somatic diseases.

Long-Chain ω-3 Fatty Acids for Indicated Prevention of Psychotic Disorders. A Randomized, Placebo-Controlled Trial.

Amminger GP, Schäfer MR, Papageorgiou K, Klier CM, Cotton SM, Harrigan SM, Mackinnon A, McGorry PD, Berger GE (2010). Arch Gen Psychiatry, 67(2):146-154

Context The use of antipsychotic medication for the prevention of psychotic disorders is controversial. Long-chain ω-3 (omega-3) polyunsaturated fatty acids (PUFAs) may be beneficial in a range of psychiatric conditions, including schizophrenia. Given that ω-3 PUFAs are generally beneficial to health and without clinically relevant adverse effects, their preventive use in psychosis merits investigation. Objective: To determine whether ω-3 PUFAs reduce the rate of progression to first-episode psychotic disorder in adolescents and young adults aged 13 to 25 years with subthreshold psychosis. Design: Randomized, double-blind, placebo-controlled trial conducted between 2004 and 2007. Setting: Psychosis detection unit of a large public hospital in Vienna, Austria. Participants Eighty-one individuals at ultra-high risk of psychotic disorder. Interventions: A 12-week intervention period of 1.2-g/d ω-3 PUFA or placebo was followed by a 40-week monitoring period; the total study period was 12 months. Main Outcome Measures: The primary outcome measure was transition to psychotic disorder. Secondary outcomes included symptomatic and functional changes. The ratio of ω-6 to ω-3 fatty acids in erythrocytes was used to index pretreatment vs posttreatment fatty acid composition. Results Seventy-six of 81 participants (93.8%) completed the intervention. By study’s end (12 months), 2 of 41 individuals (4.9%) in the ω-3 group and 11 of 40 (27.5%) in the placebo group had transitioned to psychotic disorder (P = .007). The difference between the groups in the cumulative risk of progression to full-threshold psychosis was 22.6% (95% confidence interval, 4.8-40.4). ω-3 Polyunsaturated fatty acids also significantly reduced positive symptoms (P = .01), negative symptoms (P = .02), and general symptoms (P = .01) and improved functioning (P = .002) compared with placebo. The incidence of adverse effects did not differ between the treatment groups. Conclusions: Long-chain ω-3 PUFAs reduce the risk of progression to psychotic disorder and may offer a safe and efficacious strategy for indicated prevention in young people with subthreshold psychotic states.


A prospective study of diet quality and mental health in adolescents.

Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA (2011). 
PLoS ONE 6(9): e24805. doi:10.1371/journal.pone.0024805

Objectives: A number of cross-sectional and prospective studies have now been published demonstrating inverse relationships between diet quality and the common mental disorders in adults. However, there are no existing prospective studies of this association in adolescents, the onset period of most disorders, limiting inferences regarding possible causal relationships. Methods: In this study, 3040 Australian adolescents, aged 11–18 years at baseline, were measured in 2005–6 and 2007–8. Information on diet and mental health was collected by self-report and anthropometric data by trained researchers. Results: There were cross-sectional, dose response relationships identified between measures of both healthy (positive) and unhealthy (inverse) diets and scores on the emotional subscale of the Pediatric Quality of Life Inventory (PedsQL), where higher scores mean better mental health, before and after adjustments for age, gender, socio-economic status, dieting behaviours, body mass index and physical activity. Higher healthy diet scores at baseline also predicted higher PedsQL scores at follow-up, while higher unhealthy diet scores at baseline predicted lower PedsQL scores at follow-up. Improvements in diet quality were mirrored by improvements in mental health over the follow-up period, while deteriorating diet quality was associated with poorer psychological functioning. Finally, results did not support the reverse causality hypothesis. Conclusion: This study highlights the importance of diet in adolescence and its potential role in modifying mental health over the life course. Given that the majority of common mental health problems first manifest in adolescence, intervention studies are now required to test the effectiveness of preventing the common mental disorders through dietary modification.

A randomised, controlled trial of a dietary intervention for adults with major depression (the “SMILES” trial): study protocol

O’Neil1 A, Berk M, Itsiopoulos C, Castle D, Opie R, Pizzinga J, Brazionis L, Hodge A, Mihalopoulos C, Chatterton ML, DeanOM, Jacka FN (2013). BMC Psychiatry, 13:114

Background: Despite increased investment in its recognition and treatment, depression remains a substantial health
and economic burden worldwide. Current treatment strategies generally focus on biological and psychological
pathways, largely neglecting the role of lifestyle. There is emerging evidence to suggest that diet and nutrition play an
important role in the risk, and the genesis, of depression. However, there are limited data regarding the therapeutic
impact of dietary changes on existing mental illness. Using a randomised controlled trial design, we aim to investigate
the efficacy and cost-efficacy of a dietary program for the treatment of Major Depressive Episodes (MDE). Methods/Design: One hundred and seventy six eligible participants suffering from current MDE are being randomised into a dietary intervention group or a social support group. Depression status is assessed using the Montgomery–Åsberg Depression Rating Scale (MADRS) and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (Non Patient Edition) (SCID-I/NP). The intervention consists of 7 individual nutrition consulting sessions (of approximately 60 minutes), delivered by an Accredited Practising Dietitian (APD). Sessions commence within one week of baseline assessment. The intervention focuses on advocating a healthy diet based on the Australian Dietary Guidelines and the Dietary Guidelines for Adults in Greece. The control condition comprises a befriending protocol using the same visit schedule and length as the diet intervention. The study is being conducted at two locations in Victoria, Australia (a metropolitan and regional centre). Data collection occurs at baseline (pre-intervention), 3-months (post-intervention) and 6– months. The primary endpoint is MADRS scores at 3 months. A cost consequences analysis will determine the economic value of the intervention. Discussion: If efficacious, this program could provide an alternative or adjunct treatment strategy for the management of this highly prevalent mental disorder; the benefits of which could extend to the management of common co-morbidities including cardiovascular disease (CVD), obesity, and type 2 diabetes.

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