Nutrition considerations in the behavioral health setting

Individuals receiving behavioral health care often face a unique combination of mental illness, chronic disease, medication-related metabolic complications, and social barriers that directly affect nutrition status. As behavioral health services continue to expand, dietitians are becoming increasingly important members of the interdisciplinary care team, helping improve both physical and mental health outcomes through evidence-based nutrition care. 

Current prevalence of mental health disorders 

Awareness and diagnosis of mental health disorders in the United States (US) is on the rise, which means there are more patients seeking mental health care now than ever. While there is still a stigma associated with mental health treatment, there are many efforts to increase access to care across the US. It is estimated that 1 in 5 adults and almost 1 in 2 adolescents experience some form of mental health disorder in their lifetime.  

Dietitians are specifically trained to provide nutrition education and support to help minimize mental health crises, potentially reduce symptoms related to various mood disorders, and improve quality of life for many people. With the increase in mental health treatment, there is a need for dietitians to play an essential role within the interdisciplinary team.  

Comorbidities associated with behavioral health care 

Nutrition recommendations in behavioral health settings are important due to the many comorbid conditions experienced by patients. Common comorbidities include cancer, cardiovascular disease, diabetes, chronic respiratory disease, obesity, and metabolic disorders. Nutrition is an important contributor to the prevention and management of these conditions.   

The connections between mental and physical health are multifactorial. With a higher incidence of mental illness, there are increased rates of smoking, poor diet quality, inadequate physical activity, substance abuse, limited social support, and insufficient access to medical care. To mitigate some of these negative outcomes, dietitians can use nutrition strategies to potentially improve quality of life.  

Current treatments in behavioral health settings 

Treatments currently associated with mental health care include psychotherapy modalities, such as individual therapy, group therapy, cognitive behavioral therapy, and dialectical behavior therapy. Recreational therapies, including art, physical activity, music, and games, and spiritual or holistic care are usually implemented in the behavioral health setting as well.  

Certain facilities and providers may also offer somatic treatments, such as transcranial magnetic stimulation, transcranial direct current stimulation, cranial electrical stimulation, and others. Dietitians collaborate alongside psychologists, psychiatrists, occupational therapists, recreational therapists, and nursing staff to provide comprehensive behavioral health care. 

Psychopharmacotherapy and implications for chronic health conditions  

Psychopharmacotherapy has understandably become one of the leading treatments for mental illness; however, many mental illnesses can be resistant to psychotropic medication treatment. While psychotropic medications have been shown to be effective in treating many mental illnesses, some come with the potential for significant weight changes and cardiometabolic disorders.  

Selective serotonin reuptake inhibitors (SSRIs), which are the first line of treatment for many disorders, such as depression, anxiety, and mood disorders, are considered to have generally mild side effects when compared to first-generation antidepressants. However, some studies have shown increased weight with long-term use of SSRIs. Other psychotropic medications such as atypical antidepressants, tricyclic antidepressants, MAOIs, mood stabilizers, and antipsychotics are frequently associated with weight gain and various metabolic disorders. 

What weight changes and cardiometabolic disorders are associated with psychotropic medications? 

• SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs): mild effects with short-term use, usually increased appetite with correction of poor appetite related to depressed mood; long-term increases potential for weight gain over time 
• Atypical antidepressants: bupropion is associated with weight loss, whereas mirtazapine is associated with weight gain 
• Tricyclic antidepressants: amitriptyline is associated with weight gain, insulin resistance, and diabetes  
• Monoamine oxidase inhibitors (MAOIs): weight gain, significant food/medication interaction with tyramine-rich foods 
• Mood stabilizers: lithium and valproic acid are associated with weight gain and cardiometabolic disorders 
• Antipsychotics: chlorpromazine, haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, and clozapine are associated with significant weight gain and cardiometabolic disorders 
• ADHD medications: amphetamine, methylphenidate, dexmethylphenidate, atomoxetine, and lisdexamfetamine are associated with weight loss and GI upset 

A dietitian working in a behavioral health setting must be able to identify the impact psychotropic medications can have on weight changes and the overall physical health of patients. Their role includes providing appropriate nutrition education and referrals for additional support services as indicated.  

Link between diet and mental health disorders 

The ideal approach to treatment of mental illness is a comprehensive approach with attention given to nutrition education and dietary improvements if necessary. The dietitian is in a great position to provide up-to-date nutrition recommendations in the behavioral health setting to assist in providing optimal care during treatment.  

Diet quality has frequently been linked to mental illness and mental health outcomes. Increased rates of mental illnesses are associated with diets high in saturated fats and refined carbohydrates. Better mental health outcomes are frequently associated with higher intakes of whole, plant-based foods and fatty fish. Unfortunately, the Western diet tends to be higher in refined carbohydrates, sodium, and animal-based food products.  

Nutrients of interest 

Many nutrients have been studied for their role in supporting mental health. Tryptophan, vitamins B1, B6, B9, B12, vitamin D, and iron are all essential for many neural activities that support production of neurotransmitters and neurotrophic substances. Omega-3, fiber, magnesium, zinc, and selenium all promote antioxidant and anti-inflammatory activities.  

Studies have tried to identify if supplementation with single nutrients is enough to correct possible nutrient deficiencies. Evidence for isolated nutrient supplementation is mixed and generally less consistent than evidence supporting overall dietary patterns. Supplementation may be appropriate when deficiencies are present or for specific patient populations. 

Nutrition assessment 

It’s important for the dietitian to be able to assess effectively to make relevant suggestions. Within the mental health sphere, symptoms and behaviors can vary significantly. Some symptoms related to nutrition care include appetite fluctuations, inability to focus on tasks long enough to prepare or consume a meal, food preferences and restrictions, physical comorbidities, and socioeconomic status. 

Nutrition assessment should include evaluation of: 

• Comorbidities 
• Nutrition risk factors, such as poor dentition, paranoia, sleep deprivation, and taste/texture/diet restrictions 
• Unintentional weight change 
• Disordered eating patterns 
• Education opportunities related to knowledge deficit 
• Meal planning 
• Modified diets 
• Metabolic monitoring: BMI, lipid panel, Hgb A1C, significant weight changes 

Nutrition recommendations to support mental health  

As it is with many other medical conditions, nutrition recommendations should focus on vegetables, fruits, whole grains, legumes, nuts and seeds, lentils, low-fat dairy, poultry and fish. Highly processed foods, fatty meats, butter and margarine, fried foods, and sugary drinks should be limited.  

The Mediterranean and MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diets have been studied and recommended for their benefits in supporting physical and mental health and cognitive support. Both diets incorporate high intakes of fruits, vegetables, whole grains, nuts, seeds, legumes, and fish. Additionally, they both recommend a moderate intake of poultry; however, the MIND diet recommends limiting dairy. Both diets limit red meat, processed foods, and refined carbohydrates.  

Implications for dietetic practice in behavioral health care settings 

As the prevalence of mental illness continues to rise, nutrition care should be viewed as an essential component of comprehensive behavioral health treatment, rather than an optional service. Dietitians are uniquely positioned to address metabolic complications associated with psychotropic medications, chronic disease risk, and dietary behaviors while collaborating with the interdisciplinary team. By combining evidence-based nutrition recommendations with patient-centered counseling, dietitians can help improve both physical and mental health outcomes in behavioral health settings.  

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