10 tips for better mental health & wellbeing (part 1)

The World Health Organisation (WHO) recognises World Mental Health Day on 10 October every year. The objective is to raise awareness of mental health issues around the world and mobilize efforts in support of mental health.

As a Psychiatrist, I would like to take this opportunity and talk about mental health and wellbeing not only in the context of mental (psychiatric) illness, but in a wider context applicable to most, if not all, of us.

I have to admit here that the title of this post is perhaps a bit misleading and rather simplistic. Rather than provide 10 tips, as the title suggests, I am going to look into the 10 key areas (or pillars) of daily life. I will then make a number of simple yet effective recommendations, which can maximize one’s wellbeing and contribute to a happier and healthier life.

Why me?

These recommendations are supported by my clinical experience (which includes many years of studying, training and working with thousands of people with mental health difficulties), my own research, and by having critically read a large number of wellbeing books and websites.

Let me be more specific…

The ‘biopsychosocial’ approach

As a Psychiatrist, I have been trained in the use of the ‘biopsychosocial’ approach or model to the assessment and management of the people that seek my help.

According to this model, mental illnesses (but also mental health difficulties) are rarely due to a single cause; mental illness usually develops through the complex interaction of biological (i.e. genes and chemical imbalances), psychological (i.e. personality and coping skills) and social factors (i.e. employment or financial problems).

Similarly, the biopsychosocial approach is helpful to the management of mental health difficulties and mental illness. For these reasons, mental health teams are multi-disciplinary and consist of a number of different professionals: doctors (psychiatrists), nurses, psychologists, psychotherapists, occupational therapists and social workers. A doctor’s role is to make a diagnosis and prescribe medication (biological treatment). Psychologists and psychotherapists deliver psychological therapies. Social workers and occupational therapists can help with practical and social problems.

The ‘5 p’ model

Another helpful approach is the ‘5 p’ model. A problem usually develops through the complex interaction of predisposing (which make the individual vulnerable to the problem) and precipitating factors (which trigger the problem). Perpetuating factors keep the problem going, whereas protective factors help towards recovery from the problem.

A common example: depression

Research shows that depression is often associated with an imbalance of certain chemicals (i.e. serotonin) in the brain (biological factor), and that antidepressants work by increasing the availability of these chemicals. However, we all know that certain events in one’s life tend to trigger episodes of depression (i.e. a significant loss), whereas on-going difficulties and stressors tend to perpetuate one’s symptoms (social factors). And let’s also not forget that certain individuals may be more prone to depression (psychological factor). For this reason, a holistic approach to the management of depression will have to go well beyond the prescription of antidepressant medication.

Health Research

A few years ago, I completed a Master’s Degree on Health Research. In my dissertation, I examined the evidence base for complex interventions for comorbid (co-existing) mental health problems (i.e. depression and anxiety) and long-term physical health conditions (i.e. diabetes and cardiovascular disease). These complex interventions consisted of various elements, such as biopsychosocial assessment, psycho-education, psychotherapy, medication, support for self-care, and relapse prevention. I found that they are effective in the treatment of both mental health difficulties and long-term physical health conditions.

The concept of the ‘aggregation of marginal gains’

At around the same time, I came across a concept of the ‘aggregation of marginal gains’. I’d go as far as to say that this was a ‘light bulb’ moment. Dave Brailsford, the cycling coach and manager of Team Sky, explains the marginal gains as ‘the 1 percent margin for improvement in everything you do’. The doctrine of marginal gains is all about small incremental improvements in any process adding up to a significant improvement when they are all added together. Brailsford’s belief was that if you improved every area related to cycling by just 1 percent, then those small gains would add up to remarkable improvement. I believe that the same approach can also be used in key areas of our daily life, to maximize our wellbeing and contribute to a happier and healthier life.

For these reasons, even when I prescribe medication or refer a patient for psychological therapy or to a social worker, I still come up with a list of recommendations for better mental health. I often see myself as a mental health personal trainer or coach. Like Brailsford. I am not the one lifting the weights or cycling (this will be the person who seeks my help), but I’m the one who will help them get in optimal shape or win the gold (improve their mental health).

Here are the 10 key areas (or pillars) and my recommendations:

1. Sleep

We spend one-third of our lives sleeping. But sometimes our sleep can get disrupted. In fact, a lot of people may find it difficult to fall asleep, have frequent awakenings and difficulty to get back to sleep, wake up early, have a restless sleep, or even sleep too much. There are many potential reasons why sleep difficulties occur. These include physical health problems (i.e. pain or medical conditions associated with an increased need to go to the toilet), substances (i.e. medications, caffeinated drinks, alcohol, recreational drugs) or even stress, worrying and mental illnesses (i.e. anxiety or depression).

The association between sleep and mood/mental health is bidirectional. Not only mental illnesses can affect and disrupt our sleep, but also sleep difficulties can compromise our mental health.

Sleeping tablets (or hypnotic medications) are notorious for often being ineffective (especially in the longer term) as well as for their side effects, and this is why many doctors are often reluctant to prescribe them.

The good news is that there are things you can do to improve your sleep. These are usually referred to as ‘sleep hygiene’, and, in keeping with the ‘marginal gains’ concept, they focus on a number of different areas:

• Sleep routine and consistency
• Relaxation
• Environment
• Food and drinks
• Exercise
• Worrying
• Sunlight

For further detail on how you can improve your sleep, read my post ‘Counting sheep: 7 tips for better sleep’.

2. Nutrition

As a medical student, I learned how our diet, nutrition and eating habits can affect our health. For example, a diet rich in antioxidants may protect against a number of illnesses, including cancer.

Some (non-medical) books I’ve recently read have helped me crystallize this knowledge. In keeping with Brailsford’s ‘marginal gains’ concept, these books have actually helped me introduce small changes to my daily life.

The Nordic Guide to Living 10 Years Longer

In The Nordic Guide to Living 10 Years Longer: 10 Easy Tips to Live a Healthier, Happier Life Dr Bertil Marklund talks about foods that strengthen our immune system and protect against or even cure inflammation. These are foods that contain:
• antioxidants (such as fruit and vegetables, as well as herbs and spices),
• omega-3 and omega-6 in the right proportions (such as fish, shellfish, oils, seeds, nuts and vegetables),
• fibre (such as wholegrain products, fruit, vegetables and seeds) and
• probiotics (such as yoghurt, sour milk, tomatoes, onions and sauerkraut),
• and foods with a low glycaemic index (GI) (wholegrain products, fruit and vegetables).

Ikigai: The Japanese secret to a long and happy life

Another inspiring book is Ikigai: The Japanese secret to a long and happy life. The authors pay particular attention to Okinawa, a Japanese island where people live longer than anywhere else on planet Earth. Having examined the famous ‘Okinawa diet’, they reached the following conclusions:
• Variety seems to be key; Okinawans eat a wide variety of foods, especially vegetables.
• Okinawans eat at least 5 servings of fruit and vegetables every day.
• Grains are the foundation of their diet.
• They rarely eat sugar.
• They follow a concept called ‘hara hachi bu’, which is based on a Confucian teaching that instructs people to eat until they are 80% full.

As a Psychiatrist, I have learned about the interplay between physical and mental health. I have also learned about the complex interaction between biology and psychology. Common mental illnesses, such as depression and anxiety, as well as complex syndromes, such as chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS), exemplify this. It therefore makes perfect sense how our diet, nutrition and eating habits can affect our mental health too. At the end of the day, the distinction between mind (mental health) and body (physical health) is a rather philosophical one, since the brain is part of the human body the same way that the heart or the gut are.

The Kefir Solution

A ‘lightbulb’ moment was when I recently read The Kefir Solution: Natural Healing for IBS, Depression and Anxiety. Informed by a number of scientific studies, the author discusses the biology behind IBS and explores the links between the gut and mental health. Even though she is not a doctor or a scientist, Shann Nix Jones provides some very useful insights into the role of nutrition in mental health.

UK official recommendations

In the United Kingdom, a national food guide, the ‘Balance of Good Health’ was introduced in 1994. Thirteen years later, it was revised and renamed to the ‘Eatwell Plate’. This was a visual representation based on 5 food groups and showed the proportion that each food group should contribute to a healthy and balanced diet. The plate was supported by further advice, the ‘8 tips for healthy eating’. Informed by evidence-based nutrition advice, it was revised and renamed once again in 2016. It is now called the ‘Eatwell Guide‘.

The main dietary messages of the ‘Eatwell Guide’:

• Eat at least 5 portions of a variety of fruit and vegetables every day (remember the Okinawans).
• Base meals on potatoes, bread, rice, pasta or other starchy carbohydrates, but choose wholegrain versions where possible.
• Have some dairy or dairy alternatives (i.e. soya drinks), but choose lower fat and lower sugar options.
• Eat some beans, pulses, fish, eggs, meat and other proteins (including 2 portions of fish every week, one of which should be oily).
• Choose unsaturated oils and spreads and eat in small amounts.
• Drink 6-8 cups/glasses of water a day.
• If consuming foods and drinks high in fat, salt or sugar have these less often and in small amounts.

So, in keeping with Brailsford’s ‘marginal gains’ concept, let’s make a few small improvements to our diet:

• Have three regular main meals: breakfast, lunch and dinner.
• Have healthy snacks between the main meals.
• Eat mindfully. In Eating Mindfully, Second Edition: How to End Mindless Eating and Enjoy a Balanced Relationship with Food Susan Albers recommends giving our full attention to our eating, and focusing on the process of eating and enjoying our meal. Getting rid of distractions and turning off the television/phone etc is especially important for eating mindfully.
• Do not eat too much. It is estimated that an average women needs about 2000 calories a day and an average man needs about 2500 calories a day.
• Use the UK Eatwell Guide as a guide for a healthy and balanced diet.

9 simple ways to eat healthy without thinking

In his blog, author and blogger James Clear shares 9 simple ways to eat healthy without thinking, backed by science. Many of these tips come from Mindless Eating

Use smaller plates
Make water more readily available
To drink less alcohol or soda, use tall, slender glasses instead of short, fat ones
Use plates that have a high contrast color with your food
Display healthy foods in a prominent place
Wrap unhealthy foods in tin foil. Wrap healthy foods in plastic wrap
Keep healthy foods in larger packages and containers, and unhealthy foods in smaller ones
Serve meals by using the “half plate” rule
Use the “Outer Ring” strategy to buy healthier foods

In addition to the above:

• Drink alcohol in moderation. In the UK, guidelines recommend not to drink more than 14 units of alcohol a week. Higher consumption of alcohol can exacerbate both the physical and the mental health, and may render other interventions ineffective. Recreational drugs can also have a negative effect on mental health (so avoid them completely).
• Exercise/keep physically active.

3. Exercise and Physical Activity

As a medical student, I learned that exercise and physical activity are beneficial to our physical health. For example, it helps improve our physical health by reducing risk of cardiovascular disease (such as coronary heart disease and stroke), risk for diabetes (type 2) and metabolic syndrome, and risk of some cancers (including colon and breast cancers). It also helps control our weight, strengthen our bones and muscles (therefore reducing the risk of osteoarthritis and hip fractures), and overall increase our chances of living longer.

Now a Psychiatrist, I have also learned that exercise and physical activity can be beneficial to our mental health too, including our mood and cognition. Perhaps you can see the pattern here. Healthy eating and physical activity are both beneficial to both our physical and mental health. Research has shown that exercise lowers the risk of dementia and depression, by releasing endorphins. Exercise can also foster our sense of self-worth and increase our self-confidence not only by making us feel better about our appearance, but also by helping us gain a sense of achievement and mastery. For these reasons, I often prescribe exercise and physical activity to my patients.

Is exercise and physical activity the same thing?

Not quite. Let me explain the difference. Exercise is a form, or sub-category, of physical activity, but physical activity does not require exercise. For example, gardening, walking the dog or even doing housework are all physical activities, but not exercises, whereas sports, jogging, pilates and yoga are physical activities as well as exercise.

Physical activity and exercise can be further divided into aerobic (i.e. walking jogging, dancing, swimming and gardening), flexibility (i.e. pilates and yoga), and muscle strengthening (i.e. include weight lifting, push-ups and sit-ups).

In the USA, the Physical Activity Guidelines provide science-based guidance to help people maintain or improve their health through regular physical activity. These guidelines recommend that we do at least two and a half hours of moderate-intensity aerobic physical activity over the week, which is about half an hour each day.

I personally try to walk 10,000 steps each day (aerobic activity), but I also go to a yoga class at least once weekly (flexibility exercise) and to the gym for weight lifting twice a week (muscle-strengthening exercise). Sometimes I also go for jogging and swimming (also aerobic exercises), or exercise at home.

Yoga

Out of all these activities, yoga is my favorite, as it is more than physical exercise. Having a meditative and spiritual core, as well as combining physical exercise with an awareness of breath, yoga also helps me relax and unwind. I know that yoga classes can be quite expensive, but you don’t always have to join one to practise yoga. I have recently discovered an app called ‘Down Dog’, which allows me to practise yoga at home. The YouTube channel ‘Yoga with Adriene‘ is another wonderful way to practise yoga, as well as meditation, in the comfort of your home.

So far, we have looked into 3 ‘biological’ key areas (or pillars). In Part 2 (published on the 13th of October), I am going to look the ‘psychological’ and ‘social’ ones.

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