The Real Pain of Imagined Loss

The announcement earlier this week of the engagement of Prince Harry and his partner Meghan Markle will be met with the inevitable frenzy of interest and speculation. How did he propose? What does the ring look like? Who will make her dress? This is the response we have come to expect with news of the personal life of someone in the public eye. Yet, mingled in amongst the conjecture and voyeurism will be other emotional responses; genuine joy and, for some, a curious, unexpected and somewhat embarrassing sadness. An untethered sense of loss. So, what’s going on?

To understand why complete strangers might feel sad about a prince falling in love and marrying we have to consider the nature of fantasy in our psychological lives. We are all familiar with the fantasy worlds of children in which is it common for them to create novel languages and invisible friends. Children regularly cast themselves in varied and varying roles as they experiment with emotions and relationships. As we grow we do not completely abandon these fantasy lives. Whether we rebrand these fantasies as goals (images or visualisations that we work towards turning into reality) or keep them as pleasant daydreams, the capacity to transport ourselves to another place or life remains an available tool in our emotional armory.

And it is a tool, often one that can save lives. This is what is known as the ‘Sustaining Fantasy’ and it can be the one thing that keeps the spirit going in adversity. For example, it is not uncommon for a child who experiences ongoing trauma at home to imagine that they have been the victim of a kidnap plot and that the cruel people that they live with are criminal impostors. Their ‘real parents’, who are, invariably, wealthy and kind, are out there in the world desperately seeking their lost child. You can see how holding on to this belief is a powerful coping mechanism in the face of helplessness. It can help a child hold on to the hope of their life, one day, being better. The sustaining fantasy can be a reason to not give up.

As adults we, hopefully, have access to more means to rescue ourselves from difficult situations. However, at times of high stress, sadness, dissatisfaction, disappointment or even boredom we can reignite our fantasy lives. Whether that’s imagining yourself in a different job, having great wealth, winning a Nobel or casually bumping into and marrying a bachelor prince…

For the people who have employed Harry (or any prominent person) as a character in their playful daydream or sustaining fantasy, the reality of his engagement presents them with a loss. I spoke in my podcast about grief about how abstract losses (the loss of hopes, dreams, expectations) are powerful and significant, and the sustaining fantasy falls in to this category. That real-world person is no longer a suitable character in our story and the fantasy has to be relinquished, and with it goes the pleasure, distraction or comfort it provided. This may be remedied by substituting in a new lead role (I hear Crown Prince Hussein of Jordan is still single) but it also offers the opportunity, if appropriate, for the person to address the aspect of their lives causing the dissatisfaction.

Post-Natal Depression Reduced with Probiotic Supplement

Earlier in the year we had the publication of the SMILES Trial, a study that showed a cause and effect relationship between poor diet and depression and now a new paper provides more good evidence of the role of probiotics and the gut microbiome on mental health.

Researchers in New Zealand set up a trial in which 423 pregnant women were randomly assigned to two groups. One group received a daily supplement of a strain of bacteria called Lactobacillus rhamnosus (HN001). The other group received an identical looking/tasting placebo. The women took the supplement/placebo from the moment they enrolled until their child was born, and from birth until 6 months if the mother was breastfeeding. Information about the women’s mental state was taken at baseline (14-16 weeks pregnant), when the child was 6 months and 12 months old. They found a strong effect of the probiotic. The women who had taken the supplement (and none of the women knew whether they were taking the active supplement or the placebo) were much less likely to experience depression and anxiety after the birth of their children.

Between 10%-15% of women experience post-natal depression, which can impair the development of a strong bond between mother and infant, creating psychological and physical health risks for both. Medication options for breastfeeding women are limited and it is practically difficult for women to access psychological help on top of the demands of a new baby. Further, some women feel reluctant to ask for help because they feel ashamed or guilty that they should feel so unhappy following the birth of their baby. Clearly then, the development of accessible and effective treatments is essential. There are many questions still to be answered but this study adds to the evidence of the role of gut health in mental health and of taking the health of the whole body into consideration when looking to treat mental health problems.

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial. DOI: 10.1016/j.ebiom.2017.09.013

A link between menopause and Alzheimer's?

Alzheimer's Disease and dementia are now the leading cause of death for women in England and Wales, and a leading cause of death and disability worldwide. Women have a significantly higher risk of developing dementia than men, even when taking in to account that women tend to live longer. So what's putting women at greater risk?

A new paper strengthens the evidence that oestrogen levels might be a key factor in Alzheimer's progression. Oestrogen both protects brain cells and regulates the uptake of glucose [the brain's essential fuel source] in the brain. Levels of the hormone drop substantially during the menopause, meaning that women lose these protective effects. Scanning the brains of pre-, peri- and post-menopausal women, researchers observed the the brains of women after the menopause showed lower activity [in the picture brighter and warmer colours mean increased activity], indicating that less glucose is being taken up and, potentially, that the brain cells are unable to function as well or defend against damage.

This research may help to explain why lifting weights has been shown to be particularly good for protecting brain health in older women. Resistance exercise boosts the function of the power houses within cells, helping them to create more energy. It can also increase the levels of BDNF, a compound that promotes the growth of new brain cell connections.

The evidence here will help to inform future medical treatments, but in the meantime, it might be a good idea to encourage your granny to pump some iron!

Mosconi L, Berti V, Guyara-Quinn C, McHugh P, Petrongolo G, Osorio RS, et al. (2017) Perimenopause and emergence of an Alzheimer’s bioenergetic phenotype in brain and periphery. PLoS ONE12(10): e0185926.

The Effects of Weight Training on Anxiety

We know that aerobic activity is linked to better physical and mental health. Now, a new review confirms that resistance or weight training can also support mental health. For this meta-analysis researchers reviewed 16 papers with a combined total of 922 participants. They found that resistance training significantly reduced anxiety symptoms in both healthy participants and those with diagnosed anxiety disorders. In fact the effects were larger in those without a diagnosis. And it didn't really matter if participants were much physically stronger at the end, they still got the psychological benefits, which were similar to medication and psychotherapy.

We don't know from this review whether the improvements were from psychological mechanisms (e.g. motivation, sense of achievement) or biological ones (reduced inflammation, increased brain profusion/BDNF). What we do know is that resistance training is a valuable, low cost, relatively low risk, effective intervention for anxiety. 

The Effects of Resistance Exercise Training on Anxiety: A Meta-Analysis and Meta-Regression Analysis of Randomized Controlled Trials. Sports Medicine. 2017 doi: 10.1007/s40279-017-0769-0

Gut Feelings: Using the mind to treat the body in IBS

The results of a new study strengthens the role of emotional suppression in the pathogenesis of Irritable Bowel Syndrome, a common functional gut disorder. It is time to make psychological therapy central to treatment.

Irritable Bowel Syndrome (IBS) is a functional gut disorder that affects up to 15% of people in the West. Sufferers typically experience abdominal pain or discomfort that is associated with either diarrhoea or constipation, or an alternating combination of both.

The precise cause of IBS is poorly understood and current treatment is focussed on managing the physiological symptoms, with patients typically prescribed antidiarrhoeal medication, laxatives or antacids.

However, at least as far back as 1980 IBS has been consistently associated with a range of psychological dimensions. IBS sufferers are much more likely, for example, to have experienced childhood adversity than non-sufferers, and the onset of symptoms often closely follows an intensely stressful life event.

In around 80% of cases IBS is co-morbid with anxiety, depression and somatisation (the phenomenon in which psychological distress is expressed in physical symptoms), and the greater the degree of psychological distress the more severe the IBS symptoms.

Though this association is well-established only in recent years have we really begun to understand the potential mechanisms underlying this relationship, and the explosion of research in to the gut-brain axis has provided us with a clearer understanding of how psychological or emotional pain might translate in to physical discomfort.

The current hypothesis is that persistent distress (e.g. an unhappy marriage) or chronic stress (such as unrelenting work demands) activates the immune system; the body perceives the stress as an environmental threat and prepares to fight it. This chronic immune activation affects the gut both directly – through communication via the vagus nerve – and indirectly, through inflammatory signalling molecules called cytokines. This immune activation can also disturb the composition and function of the gut microbiome, which may then contribute to further physical symptoms.

The irony, then, is that the typical pharmaological treatments may further disturb gut microbiome function. In addition, in an attempt to relieve their symptoms, sufferers may self-diagnose a food allergy or intolerance and eliminate nutrients from their diet that may exacerbate these imbalances. 

However a recently published psychological intervention offers new relief to IBS sufferers and strengthens the case for psychological therapies to form a key feature of IBS treatment.

Researchers led by Elyse Thakur at the Department of Psychology, Wayne State University in Detroit conducted a randomised controlled trial on a specialised form of talking therapy, Emotional Awareness and Expression Training (EAET), aimed at helping IBS patients to better recognise and express their emotions.

The research team compared the treatment to either relaxation training – which has been previously shown to be a helpful treatment – or to a control group of patients on waiting list for intervention. Both the EAET and relaxation groups received three 50-minute training sessions delivered over three consecutive weeks i.e. one session a week. They were assessed two weeks after the end of the last session, and again 10 weeks after that.

Participants in the EAET and relaxation groups received a similar explanation about the link between stress and IBS but the EAET group were provided with specific skills to improve emotional expression such as thinking of someone they have a difficult relationship with and being encouraged to describe those feelings out loud as if the person were present. They were later encouraged to express their emotions directly to that person. In comparison, the relaxation group were coached in muscle relaxation, deep breathing and mindfulness meditation.

At the end of the 10-week follow-up period 63% of the people in the EAET group reported significant improvements in their IBS symptoms while people in the relaxation and waiting list groups did not report any significant change in the severity of their IBS.

What is striking about this result is that the intervention was very brief, less than three hours in total, and the participants had been ill for many years. This could mean, in practical terms, that provision of this kind of treatment might be highly cost-effective. 

This was a small study with a short follow-up period, but it builds on the body of research linking psychological stress (chronic stress, unresolved trauma, emotional suppression) with the physical symptoms of IBS.

We know, and have long-known, that IBS is a stress-sensitive disorder, with symptom flare ups often triggered by stressful events, and psychological treatments have demonstrated efficacy in relieving symptom severity and improving quality of life to people living with IBS.

Perhaps it is time to move towards an integrated model of treatment that includes psychological and dietary intervention and, more broadly, it is well time that psychological dimensions were taken more seriously in the wide range of functional disorders and their treatment.

This article was originally published on September 4th 2017 on The British Psychological Society website. 


Thakur, E. R, Holmes, H. J, Lockhart, N. A., Carty, J. N., Ziadni, M. S., Doherty, H. K., Lackner, J. M., Schubiner, H. & Lumley M. A. (2017). Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial. Neurogastroenterology, Epub ahead of print. doi: 10.1111/nmo.13143

B Vitamins Reduce Symptom Severity in Schizophrenia

Schizophrenia is a serious, long-term mental health disorder characterised by experiences of distorted reality (such as visual and auditory hallucinations) and cognitive impairments such as false beliefs, paranoia, and language deficits. Though many people are able to live full lives following a diagnosis of schizophrenia, for a large proportion of patients the illness destroys their quality of life and is associated with increased mortality.

Medication saves lives but the side-effects can be distressing and debilitating, so it is essential that research continues to look for safe and effective treatments for patients. A systematic review and meta-analysis published this year by an international team of researchers found that high-dose B vitamin supplementation alongside prescribed medication reduced the severity of symptoms, particularly in those with low baseline levels, high homocysteine, and when given earlier on in the illness progression. The authors conclude that further research is warranted to understand the underlying biological mechanisms and work out which combination and dosages of nutrients would have the most benefit. -

The effects of vitamin and mineral supplementation on symptoms of schizophrenia: a systematic review and meta-analysis. 10.1017/S0033291717000022

Psychotherapy Improves Mental Health and Daily Functioning in Irritable Bowel Syndrome: Meta-Analysis

Last year I reported on a study that showed that psychotherapy was effective at reducing the physical pain of Irritable Bowel Syndrome (IBS) and that, at the same time, it was superior to medication at reducing healthcare costs associated with the illness. A new meta-analysis extends the work on psychological treatments for IBS and shows that talking therapies are also effective for improving the mental health and quality of life sufferers. Quality of Life is a psychological measure that looks at the wellbeing of an individual or group and can assess how much satisfaction they derive from their lives or from an aspect of it, such as work or relationships. IBS can reduce quality of life by getting in the way of normal daily activities like work or socialising and can create mental distress but, for example, increasing anxiety around eating and meal times, depression and, in severe cases, suicidal thoughts.

This new meta-analysis looked not only at the efficacy of psychotherapy on improving mental health in IBS sufferers but also at which type of therapy was most effective. The researchers collated 31 randomised controlled trials that provided data on overall mental health and daily functioning of nearly 2000 individuals from different countries. The researchers found that all kinds of psychotherapy were effective at improving psychological wellbeing, people felt better. When it came to daily function cognitive behaviour therapy (CBT) appeared to be the most effective, compared to psychodynamic, hypnosis or relaxation therapy.

Whilst this research is encouraging in relation to the value of therapy in treatment of IBS it does present with a number of problems. First, the researchers have been unable to distinguish between what types of CBT were being provided. For example, some ‘brands’ of CBT focus more on mindfulness, whilst others focus on acceptance and behaviour change. It may be that there is further variability within these groups. In addition, CBT was by far the most studied therapy. Looking at mental health, for example, there were 19 CBT trails compared to 3 psychodynamic. More research on other types of psychotherapy will be useful to add strength to the conclusions. Also, another paper published this year suggested that though CBT did lead to improvements in quality of life for IBS sufferers the results did not last long after the therapy ended.

What we can be surer of is that psychological therapy does improve the mental wellbeing of IBS patients and can be an important tool in helping improve their quality of life. Though there is further research required this meta-analysis adds to the body of research highlighting the powerful role that psychological therapies play in IBS treatment.



Laird, K. T., Tanner-Smith, E. E., Russell, A. C., Hollon, S. D. & Walker, L. S. (2017). Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis. Clinical Psychology Review, 51, 142-152

Dehkordi AH, Solati K. The effects of cognitive behavioral therapy and drug therapy on quality of life and symptoms of patients with irritable bowel syndrome. Journal of Advanced Pharmaceutical Technology & Research. 2017;8(2):67-72. doi:10.4103/japtr.JAPTR_170_16.

Competitive Under-Eating: That Harmful Thing You are Probably Doing and Why You Have to Stop

Joey Chestnut stands at 6 foot 1inch tall but in the world of competitive eating his figure looms much larger. In 2016 he regained the championship belt by consuming 70 hotdogs and buns in 10 minutes. Two month later he held on to the US Chicken Wing Eating Championship by eating 188 wings in 12 minutes. Joey trains for his feats with a combination of fasting and stretching his stomach by drinking gallons of water. It’s a dangerous ‘sport’ as the legal disclaimers attest. The harms of competitive eating are obvious and well-documented so I am not going to talk about them here. I’m concerned about a competitive eating behaviour that happens towards the other end of the spectrum.

Competitive Undereating doesn’t draw the same crowds as Joey and his rivals – though it does require an audience of sorts – and there is isn’t any prize money. There is nothing in it but a misguided sense of triumph, the creation of tension at mealtimes and the risk of psychological harm. Competitive Undereating is a subtle and complex behaviour where a person strives to demonstrate that they have or will eat less than someone else. It can be used to signal that eater isn’t ‘greedy’ or ‘bad’ or that they have superior ‘control’ over their appetites. It is linked with maladaptive perfectionism (the unhealthy kind) and can trigger more serious eating issues in the eater and those around them.

Shared student houses are a hotbed of dietary restriction and I think it is linked to Social Comparison Theory. This theory states that to manage our self-esteem we are driven to make comparisons between ourselves and others. A downward comparison means we look for someone who is ‘worse’ than us to make ourselves feel better. For groups where academic achievement is on a par (such as medical students, for example), physical appearance and attractiveness are the next best targets for comparison. Moving out of home and having to manage budgets and meals for the first time is stressful and can lead to the development of harmful behaviours in those vulnerable. Being thrown in to a group living situation can raise worries about whether you or the way you eat is ‘normal’. Do you eat the ‘right’ foods? Does the way you eat seem weird to other people? Added to that is the unconscious drive, when we are in groups, to establish a hierarchy to see who is the ‘Alpha’. Now the conditions are set for the flourishing of anxiety-driven competition.

But it is not just in unrelated groups. It is common to find Competitive Undereating among households. Siblings do it against each other, especially if one child has already been dubbed ‘The Thin/Small/Skinny One’. Mothers do it with their daughters more than society would like to admit.

Competitive Undereating is not an eating disorder, though it is a sign of disordered eating. I am sure, though, that most people who engage in this harmful, unproductive behaviour don’t even realise it. Simply, they have been around it, and doing it for so long that they do not even notice anymore. Worrying about what someone else thinks of our eating instead of what we ourselves want has become automatic. To understand whether you, or someone around you, is a Competitive Under-Eater, you need to first know what it looks like. Family or group mealtimes are where this kind of behaviour is most obvious. Let’s imagine you and your housemates/friends/colleagues/family are going out for dinner…


The competition begins long before arrival at the chosen eatery. Perhaps the choosing of typically low calorie cuisine (e.g. Thai, Japanese or vegan) is an attempt to minimise calorie consumption from the outset. For a Competitive Under-Eater the venue can be the first signal of status. ‘I’m choosing the healthy option because that’s better. I don’t allow my cravings to determine my choices’. If not, if, say, the choice is pizza or burgers then the menu is scanned beforehand, not for efficiency, or in excited expectation, but to find the lowest calorie, healthiest item. The ‘best’ choice.

At The Restaurant

At the restaurant or dinner table we begin to see the different types and strategies of Competitive Undereating. I call them The Proclaimers, Surveyors, Sirens and The Compensators.

The Proclaimers

Sadly, I am not talking about the cheerful Scottish duo (but now the song is in your head). These Proclaimers take two forms, but both involve making an announcement about previous eating.

‘I haven’t eaten anything all day!’ It is less important whether this is or is not a factual statement. The point of the proclamation is set the Proclaimer out as the most ‘controlled’, the best denier of hunger. In a world where being thin is the sign of success, not eating all day is an achievement.

Of course, not everyone who turns up at dinner saying they are starving is competitively undereating. What’s we’re talking about here is the meaning, the intent behind the statement.

The alternative proclamation is something along the lines of, ‘I’ve already eaten’ or ‘I had a big lunch’. This is incredibly common in restrictive eaters and serves to legitimise later under-eating. It is a pre-emptive strike aimed at stopping others from enquiring why they are eating so little.

The Surveyors

Surveyors take an audit of the menu choices of the rest of the group.

  • What are you having?
  • How many courses are you going to have?
  • Are you going to have bread?
  • Are you going to get dessert?

Again, this is less about the specific behaviour. There are plenty people who are so excited by the whole menu that they just want to talk about. In the mind of a Competitive Under-Eater, though, the value of the survey is to inform their own selection. ‘Well, I don’t want to be seen to be having more than anyone else. I don’t want to look greedy. I don’t want them to think that I eat ‘too much’.’ For this person finding out what everyone else is having is driven by the anxiety of not wanting to stand out or seem different.

The Sirens

I call this group/behaviour the Sirens because, like the mythological creatures, they lure others in to a trap. For example, they may talk about how delicious the dessert menu looks, how they have been craving cheesecake all week. When it comes time to order, feigning indecision, they insist that everyone else order first and then, at the very last moment, decline. The satisfaction here is knowing now that others will be eating more than they have and again signalling their superior ‘control’.  

The Compensators

Whether it comes at the start or the end of the meal Compensators make a public statement about ‘working off’ their food, of the need to undo the harm of eating. Comments like:

‘I’m gonna have to go for the longest run in the morning!’

‘It’s a good thing I did spin this afternoon!’

They may not have under-eaten but this kind of comment makes clear that the speaker has or will have a calorie deficit compared to the other diners and suggests that everyone else should emulate their behaviour.  

What’s The Problem?

The reason this kind of behaviour concerns me is because of the psychological repercussions. Imperceptible at first, with time the behaviours can bed in to become an established pattern.

To start with Competitive Undereating habitualises the judgement of self and others. Silent disapproval becomes second nature. It means that even (or especially) when sitting down to eat everyone at the table is being quietly assessed and critiqued. It creates anxiety (which in itself impairs digestion) and prevents full enjoyment of the meal. It gets in the way of real, healthy social interaction. Competitive Undereating comes between people because, ultimately, the attention is focused back on the self. Whatever the other people are doing or eating you are always thinking about how it relates to, reflects on or affects you.

Secondly, it consumes thinking and is a colossal waste time, energy and creativity.

Third, Competitive Undereating can trigger and perpetuate eating disorders, and hinder recovery. It can be incredibly difficult for someone in recovery to start to rebuild a healthy relationship with food if they continue to be exposed to Competitive Undereating or judgement about their food choices. Not least of all because comparing your food intake to someone else’s ignores biological, metabolic, genetic, hormonal and lifestyle differences between you.

Competitive-Under-Eating looks harmless but it can lay the foundations for deeper problems with food, eating and self-esteem. If you recognise yourself or someone close to you as a Competitive Under-Eater it can be helpful to remind yourself that what you eat does not affect other people and vice versa. It’s dinner. It’s not a competition.


If you think you might have a problem with your relationship with food it may be helpful to talk to a professional. Psychologists and registered nutritionists who specialise in Intuitive or Mindful Eating can help you develop a more relaxed, natural relationship with food.

Depression is a Whole-Body Disorder. Why Don’t We Treat It Like One?

Today marks the start of Mental Health Awareness Week in the UK. In previous years the campaign has explored the experiences of living with mental illness, social stigma and support resources. This year the focus has changed from living with illness to asking why so few of us are thriving psychologically. Why are so many of us in ‘survival mode’? It’s an approach that invites us to look at the wider factors influencing mental health on a sub-clinical level. When most of the people who experience depressive or anxious symptoms will not or cannot access treatment it is important to understand other viable and effective avenues for intervention.

This broader theme of what it means to ‘thrive’ reflects a growing appreciation that disorders such as depression are not simply ‘brain-based’ but are biological and psychological responses to social, environmental and lifestyle factors. Just a few days ago a review of 20 years of depression research concluded:

“…one thing is for sure: depression, and mental health problems in general, can no longer be seen only as disorders of the mind, or indeed only as disorders of the brain. The strong impact of the immune system on emotions and behaviour demonstrates that mental health is the health of the whole body.”

Two years ago the Lancet Psychiatry released a statement editorial highlighting that ‘nutrition is as important to psychiatry as it is to cardiology’ and advocated that nutritional status and dietary intervention should be considered when assessing a person’s mental health condition. The recent publication of the ‘SMILES’ Trial was the first study to elucidate diet as a causal factor in depression. Mood improvement in this study was not a factor of weight loss and while this particular study did not assess these parameters it is likely that the improvement was due to a reduction in systemic inflammation, as has been highlighted by a number of observational and RCT trials.

Inflammation is the immune system’s response to illness or injury, which, amongst other things, involves the release of small molecules called cytokines by immune cells. Typically, the inflammatory response is brief and begins to recede when the tissues start to heal. However, a number of stressful external factors also induce inflammation and the secretion of pro-inflammatory cytokines including: early life adversity, traumatic events, chronic work stress, poor diet, obesity and a sedentary lifestyle. When stress is sustained so is inflammation and this state of low-level chronic inflammation is implicated in a range of diseases including heart disease, Type 2 diabetes, Alzheimer’s Disease, and depression. Blood levels of inflammatory cytokines correlate with the severity of depression that patients report. In one trial non-depressed participants were injected with a substance called endotoxin, a toxin found in the cell walls of bacteria that the immune system recognises as harmful. The participants who were injected with endotoxin not only saw an increase in their levels of cytokines but reported significantly increased anxiety, depressed mood and loss of pleasure (a symptom of depression). The participants who received the placebo did not report these mood effects.

As well as improving diet, exercise has been shown to be effective in reducing levels of inflammation, improving mood and increasing the levels of a substance called BDNF. BDNF is a growth factor that promotes the growth of new brain cells, as well as protecting the ones we already have. Low levels of BDNF have long been associated with depression and other mental illness. Exercise mimics the action of antidepressants by raising levels of BDNF and improving the availability of the neurotransmitter serotonin, which is associated with good mood. Exercise has the additional benefit of improving heart health and general brain structure and function, and improving sleep (sleep disorders are a common factor in depression).  Taking a similar position to the Lancet Psychiatry report, a recent editorial in the journal General Hospital Psychiatry makes the case that the evidence for the beneficial effects of exercise on mental health is so compelling that it is time to start thinking about how to apply it as treatment.

Other lifestyle factors have also been shown to be effective in improving mental health including meditation, learning, fasting and even sauna use. Combined, these factors present us with the best cost-effective opportunity to reduce and prevent the development of depression and associated disorders. Sadly, few people will have access to this valuable information and support. Conducting a thorough assessment into what might be causing one person’s depression takes more time than the ten minutes GP’s are allotted per person. Psychological therapies are effective but can be difficult to access. Thus, antidepressant medication remains the most cost-effective treatment available in Primary Care. The problem is that rates of treatment-resistance (patients not responding to antidepressants) are increasing. The lifestyle factors outlined above provide opportunities to both improve the efficacy of standard treatments and as standalone options for those with mild-moderate symptoms.

Hopefully, this year’s campaign will make the case for considering lifestyle interventions in the treatment of depression. For my part, my clinical practice starts with a comprehensive assessment of both psychological and lifestyle factors including: work satisfaction; relationships; childhood illnesses, exercise; diet and nutrition, and sleep habits so that the client and I can come to as clear an idea as possible of what might be causing their distress and illuminate a number of areas for intervention to give us the best chance for a positive outcome.

To increase the availability of this valuable information I am launching a series on online seminars on a range of topics including Stress Management, Sleep, Nutrition and Obesity. It’s times for us to move away from a model of symptom management to one of illness prevention, and all change starts with awareness.


Dantzer, R., O'Connor, J. C., Freund, G. G, Johnson, R. W, Kelley, K. W. (2008). From inflammation to sickness and depression: when the immune system subjugates the brain. Nature Reviews Neuroscience, 9(1), 46–56. doi:10.1038/nrn2297

Ekkekakais, P. & Murri, M. B. (2017). Exercise as antidepressant treatment: Time for the transition from trials to clinic? General Hospital Psychiatry. Doi 10.1016/j.genhosppsych.2017.04.008

Miller, A. H., & Timmie, W. P. (2009). Mechanisms of Cytokine-Induced Behavioral Changes: Psychoneuroimmunology at the Translational Interface Norman Cousins Lecture. Brain, Behavior, and Immunity23(2), 149–158.

Pariante, C. M. (2017). Why are depressed patients inflamed? A reflection on 20 years of research on depression, glucocorticoid resistance and inflammation. European Neuropsychopharmacology. In press.

Sarris, J. et al. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271-274.

Talking Mental Health Self-Care with Laura Thomas PhD.

Many of you will have watched the moving and insightful BBC documentary Mind Over Marathon, which followed 10 volunteers, each with their on mental health concern. Part of the Heads Together mental health awareness campaign, the programme followed the volunteers as they used training for the London Marathon both as a personal challenge and treatment. I have written elsewhere about the value of exercise as a mental health intervention and it is great to see it receiving more recognition for its benefits.

Laura Thomas PhD was the nutrition consultant on the programme and on the latest episode of her podcast we talk about the five pillars of mental health self-care, the role of nutrition on brain health and dinosaurs. Enjoy!


Treating Depression with Diet: The 'SMILES' Trial

Regular readers of this blog or anyone who follows me on Twitter for even half a day will be familiar with some of the research on lifestyle interventions for mental health. While these include sleep, exercise and creative pursuits, one of the ones that I keep coming back to is diet. I have reported on epidemiological studies that show a relationship between a consistently healthy diet and depression in the general population and in women. This research has been correlational, it shows that there is a relationship but, technically, cannot say that what causes what. It could be that depressed people are more likely to eat a poor diet. All that changed recently with the publication of a randomised controlled trial of the use of diet as a treatment of depression; The ‘SMILES’ Trial. The research was led by Professor Felice Jacka, who, if you are interested, I recommend you follow on Twitter for updates and links to similar research.  

The 67 participants in this 12-week Australian study were adults who were depressed at the time and who had a clinically defined poor diet. A poor diet was one that was low in fibre, fruit and vegetables and lean protein, and high in sweets, salty snack foods and processed meats. Some participants were receiving treatment in the form of medication, talking therapy or both.

The participants were randomly assigned to either a nutritional intervention group or a befriending control group. In the intervention group the participants had seven one-hour sessions with a registered nutritionist who provided them with personalised nutritional advice including example recipes and meal plans, and coached them around goal setting and motivation to help them to stick to the nutritional recommendations. They were encouraged to eat (servings in brackets):

  • Whole grains (5–8 servings per day);
  • Vegetables (6 per day);
  • Fruit (3 per day); 
  • Legumes/beans (3–4 per week);
  • Low-fat and unsweetened dairy foods (2–3 per day);
  • Raw and unsalted nuts (1 per day);
  • Fish (at least 2 per week);
  • Lean red meats (3–4 per week);
  • Chicken (2–3 per week);
  • Eggs (up to 6 per week); and
  • Olive oil (3 tablespoons per day).

In addition, participants were encouraged to reduce their intake of “‘extras’ foods, such as sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). Red or white wine consumption beyond 2 standard drinks per day and all other alcohol (e.g. spirits, beer) were included within the ‘extras’ food group. Individuals were advised to select red wine preferably and only drink with meals.” They were told to eat to their appetites and not worry about trying to lose weight, so it wasn’t a ‘diet’ in the colloquial sense. Those in the social support/befriending group had seven one-hour meetings with a trained professional who talked to them about neutral subjects (i.e. not nutrition, mood or anything that might be considered therapy). Anxiety, depression and general mood were assessed at the beginning and end of the study, along with biological data such as weight, waist circumference, fasting blood glucose and cholesterol.

People in the dietary intervention group were four times more likely to be in remission (not depressed) at the end of 12 weeks than those in the befriending group. They also had reduced severity of anxiety symptoms. There was no change in BMI, blood glucose, cholesterol or physical activity within or between the groups. People were not feeling better because they had lost weight but they were definitely feeling better.

What is also interesting is an analysis called the Number Needed to Treat (NNT). The NNT is a rating of a treatment’s efficacy and describes the number of people that need to be on the treatment in order for one unwanted outcome to be prevented or avoided. So, if a (miracle) drug worked for absolutely everyone then the NNT would be 1. If, for example, a migraine treatment had an NNT of 100 then 100 people would need to be on the treatment to prevent one person having a migraine. The NNT in the SMILES Trial was four. This compares favourably to common antidepressant medication which can vary from 5-16, which is still considered effective particularly in relation to the high global rates of depression. The authors also make the point that that this nutritional intervention would also have positive outcomes for other problems that are commonly associated with depression such as heart disease, type 2 diabetes and obesity.

Crucially, the researchers also looked at the affordability of the diet and found that, on average, people adhering to the diet spent $26 less per week on food and drink than they were at the start of the study.

Of course, we have to bear in mind that this was a small study of people from a particular part of the world and it will both interesting and exciting to see the trial replicated with more participants from different ethnic backgrounds. However, it is also, I think, hugely important. It is the first study (as far as I can see) that demonstrates a direct influence of diet on depression. Depressed people who improved their diet felt better. This trial doesn’t tell us how the diet had this beneficial effect; the results were unrelated to any of the other measurements they took. My guess is that future replications will find a link to systemic inflammation and perhaps to action of the gut microbiome, but time will tell. The upshot is that improving diet in line with general guidelines (no extreme diets) had a significantly positive effect on depression. The benefit of this kind of intervention is that there are no waiting lists or side-effects, and it doesn’t have to be expensive. We eat several times a day and this research shows us that each meal provides us with a valuable opportunity to make a difference to how we feel.


Jacka, F. N., O’Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., Castle, D., Dash, S., Mihalopoulos, C., Chatterton, M. L., Brazionis, M., Dean, O.M. Hodge, A. M. & Berk, M. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). BMC Medicine15, 23.

Out of the Mouths of Babes

Just before Christmas I was at an artisan food market in my other guise as a food producer. To my left and juxtaposed against Glamorous Jam was a friend and baker who specialises in ‘clean cakes’; free from refined sugar, wheat flour and with lots of raw, ‘plant-based’ ingredients. She has developed something of a cult following with people returning from a local yoga class looking for a ‘guilt-free treat’. That morning the baker was engaged in a conversation with a fan; a mother who was telling her about her ethos on food. Sugar is poison and verboten in her home. She spoke with pride about how her husband used to cook a lot of the meals when they first dated but how she refused to let him cook now; from the moment that she became pregnant with their daughter she had taken total control of the kitchen.

As she spoke her daughter wandered off and approached me. Bright and inquisitive she asked,

‘What’s that?’

‘It’s jam.’

‘Does it have gluten in?’

‘No, it doesn’t. Why do you ask?’

‘I’m not allowed to eat gluten.’

‘Why is that?’

‘I don’t know I just know that it is bad.’ She paused and then asked, ‘How do you make it?’

‘Well, you put some fruit and some sugar in pan and….’

She interrupted with a gasp and her tiny face pinched into an expression mixed of disgust and dismay. ‘It’s got a lot of sugar in it!’

‘Well, yes, it has.’


‘How old are you?’


She turned and walked back towards her mother who was preparing to leave when the girl pointed to a small dial operated vending machine, the kind that sells only one product. There were two machines side by side. One selling Pringles and the other Skittles. The girl pointed, could she try some of those?

‘NO!’ This was from both her mother and the baker.

‘You don’t want those. Those are disgusting!’ the baker told her.

‘No, you must never eat those,’ her mother added, ‘Listen to what she says. She is a master chef so she knows.’

This conversation left me disturbed for a number of reasons, all related to my work as a psychologist working with people struggling with disordered eating and eating disorders. With the caveat that I know nothing about this woman – I don’t know whether it was difficult for the couple to conceive or whether her daughter was a sickly infant. I know nothing about the mother’s own history with food. My thoughts are solely a synthesis of my clinical experience and my observation of both this mother and child.

My fear is that it will be impossible for this young girl to grow up without a conflicted relationship with food, for the following reasons:

1. This girl is explicitly being taught to fear food. She doesn’t know why but she knows that gluten is ‘bad’. Maybe she is gluten intolerant. Maybe. I got the sense that she was bright enough to say if she had been diagnosed with Coeliac Disease. That did not seem to be the case. Rather she had a vague sense of the ability of gluten to harm her. Others have written at length about the lack of plausible evidence behind this assertion, but often, in online wellness blogs and books, gluten is demonised as an anti-nutrient. In truth it is employed as a specious reason to restrict carbohydrate intake for weight loss reasons. But the largely unfounded warnings about its dangers persist.

2. What is implicit in this ‘How to Fear Food: 101’ is what this young girl is being taught about her body. The human body is incredibly resourceful and robust and childhood is a time of rapid cell growth, development and repair. It is a time of exploration and discovery of what the body is capable of and the carefree joy of movement. Yet, already at the age of six, this girl is being taught that her body is fragile and that a handful of crisps present a significant danger to it.

3. She will come to understand that her mother’s approval of her is linked to the types of food that she chooses to eat. To put it another way she will learn that, at least in this aspect, her mother’s acceptance of her is conditional; she can please or displease her mother based on the food she chooses to put in her own body. This is particularly harmful in a society where girls are taught to be good, sweet and obedient. This kind of conditioning prevents her from learning to make food choices based on her own appetite and wants. As a consequence, it will, I believe, be much harder for this young girl as she grows up to drown out the external rules about food and the voices – from magazines, untrained bloggers, peers etc. – telling her what she should eat.

4. Clearly this young girl is curious about these forbidden foods. We know that making a food off-limits, whether we are dieting or under instruction, tends to make that food more attractive and encourages food rumination (excessive food thoughts). Caught between her innate curiosity and the restrictions imposed by her mother I worry that the scene is set for later binge and/or secret eating. It is easy to imagine: as an adolescent with greater control over her diet she perhaps sees her friends eating foods that have been denied her and suffering no obvious ill effects. Knowing that her mother would not approve, and, on some level, having internalised this contempt for sugar-sweetened or ‘unclean’ foods, she can only allow herself to eat them furtively, in secret. Perhaps she must have as many of them at once. Afterwards, knowing that she has transgressed, she experiences a deep sense of guilt and ‘weakness’ for not having been able to resist these foods. To get rid of this feeling and in order to feel ‘clean’ again she purges and returns to the clean, ‘safe’ foods, until the next time.

5. Alternatively, she simply rebels. A part of her, angry and frustrated by the intense dietary scrutiny and control that has been exercised over her, just chooses to disobey. Susie Orbach’s (1978) seminal work on women’s struggles with food and their bodies poses the argument that, for many women, obesity is the physical manifestation of a psychological rebellion against the familial and societal mores placed on women.

I recently saw this mother and child again. The mother came to find the clean cakes but, discovering them unavailable, she was not interested in anything else. As the mother asked about the absent vendor her daughter wandered towards another stall. There stood two talented patissiers, the pastry chefs for a renowned middle-eastern chef and food writer, displaying their handmade cakes. Caramelised brownies concealing a clever layer of crisp feuilletine; a perfectly straight-edged all-butter sablé tart filled with fragrant passion fruit curd and topped with a fan of spiced, marinated fresh pineapple. Delicious foods made with excellent quality ingredients by skilled and passionate chefs. Before the girl could ask about them her mother called her away. There was nothing here for her.

I hope this does not read as a castigation of a mother who I understand is trying to do the very best for her child. Evidently, she and her partner are doing a good job: they are raising an inquisitive, confidant daughter. I will be joyous with relief to, in 10 years’ time, be proved undisputedly wrong. But when I work with young women (the majority of my work with eating disordered clients has been with women, both individually and in groups) who have so lost connection with their own bodies that they cannot tell whether they are hungry or full. When they describe how they ‘know’ their value to their parents is contingent on their appearance. When their own opinions have been so degraded that they don’t even bother to disagree anymore, not at least with words, instead their rage is expressed through their aggression towards their own bodies. When you sit with someone who is in despair about whether they deserve dinner, you become less hopeful. Not hopeless, never hopeless, but the path between what I saw in the market and what I see in clinic is well-trodden, and it makes me sad for the loss of freedom and vibrancy in these beautiful young people.

And that’s why I am angry. Because I worry about the lost hours, months and years of discovery, pleasure and productivity that lie ahead for children and adolescents raised in environments of harmful restriction and food fear. When children are taught to ignore their appetites, deny their curiosity, and distrust their own bodies. When, at the same time that they are being taught that it is morally wrong to hit, kick or be unkind, children are receiving messages about the ‘goodness and badness’ of certain foods, their own appetites inappropriately become part of a moral dilemma. Am I a bad person for wanting to eat crisps? Will my mother be hurt if she finds out I ate those biscuits? Somewhere down the line these questions mutate into a deeply held doubt as to whether their bodies are truly their own or whether other people will always have the right to tell them what to do with them. Of course, we need to raise our children with an appreciation of healthy and delicious foods and a caring respect for their bodies, but this must be done free from emotional conditions, nameless fear and moralising or else their physical health will be the least of our worries.




Hart, K. E. & Chiovari, P. (1998). Inhibition of eating behaviour: Negative cognitive effects of dieting. Journal of Clinical Psychology, 54, 427-430.

Herman, C. P., & Mack, D. (1975). Restrained and unrestrained eating. Journal of Personality, 43, 647–660.

Orbach, S. (1978). Fat is Feminist Issue. London: Paddington Press.

Sumithran, P., Predergast, L., Delbridge, E., Purcell, K. Shulkes, A., Kriketos, A., & Proietto, J. (2011). Long-Term Persistence of Hormonal Adaptations to Weight Loss. New England Journal of Medicine, 365, 1597-1604.

New Year's Resolutions Worth Making: Week 2 - Food

At this time of year the word ‘diet’ is exclusively used to refer to the new 4, 8 or 12 week plan that will help you ‘drop a dress size’ or ‘blast belly fat’. In fact, when people think about the functions of food they will usually think about its role in fuelling or reshaping the body; it’s unusual for us to think about the influence of diet on brain structure and function. Even though we have an understanding that nutrients from food are important for the health of our organs, e.g. ‘eat carrots for better night vision’ and might even go as far as taking supplements to improve the condition of our skin or hair, we neglect the brain, forgetting that it too is an organ and relies on nutrients from the diet for optimal function. In fact, though your brain makes up only about 2% of your total body weight it accounts for nearly 25% of the body’s energy requirements; it has a huge nutritional demand. So, this January how about making a resolution to take better care of your brain?

A Quick Note on Omega 3s

If we took your brain out of your head, removed all the water, 60% of what was left would be fats, and especially omega 3s. Omega 3 fats are essential fats, ‘essential’ meaning they are crucial to brain function but the body is unable to synthesise them; they must be taken in through the diet. These fats are critical for the normal development of the brain.

There are three forms of omega-3: ALA, EPA and DHA. ALA is the version found in plants, things like chia seed (although they are also relative high in phytates that can reduce the absorption of important minerals) and flaxseeds. EPA and DHA are found in marine sources; oily fish and other seafood. The NHS recommends that we eat two portions of fish per week, of which one should be oily but barely anyone is achieving that intake. DHA is the most abundant essential fat in the brain and is understood to be particularly important for brain development so it is critical during pregnancy, infancy and childhood. As we age EPA comes in to its own providing a protective, anti-inflammatory action as well as supporting neurochemical synthesis and transmission. It’s actually very difficult for the body to make use of ALA; it can use it to synthesis EPA and DHA but not very efficiently and only in tiny amounts so people who avoid animal products and are unwilling to take a fish oil supplement are likely to be deficient.

Supplementation with EPA + DHA has been shown to improve memory performance(2), vocabulary and non-verbal reasoning (3) and may prevent age-related brain shrinkage (4). It may also play a preventative role in the disease course of Alzheimer’s Disease, now the leading cause of death in England and Wales (5). Older people with mild cognitive impairment who were supplemented with DHA and EPA improved their depression scores (6). Omega 3s may also play a preventative role in post-partum depression (7).

General Diet

A number of studies have shown a positive effect of a healthy diet on brain health and mood. Polyphenols are the anti-oxidant compounds found in berries, green tea, vegetables, spices and cocoa and they have been shown to have a protective effect on brain cells and can even promote the growth of new ones. Flavanols (a type of polyphenol) in cocoa can increase the flow of blood to the brain and as a result may improve cognitive functions such as attention, learning and memory (8). Consuming polyphenols can promote the production of BDNF, a protein that stimulates the growth of new brain cells (9). Low levels of BDNF in the brain have also be implicated in the development of brain disorders such as Alzheimer’s Disease, Parkinson’s, depression, bipolar disorder and schizophrenia (10). Though there is some question about exactly how polyphenols themselves may act on the brain it is a consistent and robust finding that people who consume diets high in polyphenol rich foods (leafy green and brightly coloured vegetables, berries, spices) are less likely to develop depression and age-related decline in brain function. In 2008 a plant- and omega-3-rich diet was suggested as a preventative strategy for Alzheimer’s Disease (11). More recently a large American trial tested a modified Mediterranean Diet and found that it was linked to a lowered likelihood of developing Alzheimer’s (12). A large Spanish studied that followed 15,000 people over 10 years found that, after controlling for other factors such as smoking, activity levels and BMI, those who ate the healthiest diets were up to 30% less likely to become depressed (13).

So, when we’re talking about a diet that protects the brain the evidence suggests that 500g of vegetables and fruit, 10g of dark chocolate, a small glass of red wine and four cups of green tea per day is effective, and supplemental omega-3s may also be beneficial.

Next week I’ll be talking about how exercise can change the structure and function of your brain. Until then, eat your greens!



1. Hamazaki, K., Harauma, A., Otaka, Y., Moriguchi, T. & Inadera, H. (2016). Serum n-3 polyunsaturated fatty acids and psychological distress in early pregnancy: Adjunct Study of Japan Environment and Children Study. Translational Psychiatry, 6, e737. doi: 10.1038/tp.2016.2

2. Yurko-Mauro K., Alexander D.D., van Elswyk M.E. (2015). Docosahexaenoic acid and adult memory: A systematic review and meta-analysis. PLoS ONE. 10:99

3. Muldoon M.F., Ryan C.M., Sheu L., Yao J.K., Conklin S.M., Manuck S.B. (2010). Serum phospholipid docosahexaenonic acid is associated with cognitive functioning during middle adulthood. Journal of Nutrition,140, 848–853. doi: 10.3945/jn.109.119578

4. Conklin S.M., Gianaros P.J., Brown S.M., Yao J.K., Hariri A.R., Manuck S.B., Muldoon M.F. Long-chain omega-3 fatty acid intake is associated positively with corticolimbic gray matter volume in healthy adults. Neurosci. Lett. 2007;421:209–212. doi: 10.1016/j.neulet.2007.04.086.


6. Sinn, N., Milte, CM., Street, S. J., Buckley, J. D., Coates, A. M., Petkov, J. & Howe, P. R. (2012). Effects of n-3 fatty acid, EPA and DHA, on depressive symptoms, quality of life, memory and executive function in older adults with mild cognitive impairment: a 6 month randomised control trial. British Journal of Nutrition, 107, 1682-1693.

7. De Vriese, S. R., Christope, A. B. & Maes, M. (2003). Lowered serum n-3 polyunsaturated fatty acid (PUFA) levels predict the occurance of post-partum depression: further evidence that lowered n-PUFAs are related to major depression. Life Science, 73, 3181-3187.

8. Lamport, D., Pal, D., Moutsiana, C., Field, D., Williams, C., Spencer, J. and Butler, L. (2015) The effect of flavanol-rich cocoa on cerebral perfusion in healthy older adults during conscious resting state: a placebo controlled, crossover, acute trial. Psychopharmacology, 232, 3227-3234.

9. Murphy, T., Dias, G. P. & Thuret, S. (2014). Effects of diet on brain plasticity in animal and human studies: Mind the gap. Neural Plasticity,  doi:  10.1155/2014/563160

10. Gomez-Pinilla, F. & Nguyen, T. T. J. (2012). Natural mood foods: The actions of polyphenols against psychiatric and cognitive disorders. Nutritional Neuroscience, 15, 127-133.

11. Kidd, P. M. (2008). Alzheimer's disease, amnestic mild cognitive impairment, and age-associated memory impairment: current understanding and progress toward integrative prevention. Alternative Medicine Review, 13, 85-115.

12. Morris, M. C., Tangney, C. C., Wang, Y., Sacks, F. M., Bennett, D. A. & Aggarwal, N. T. (2015). MIND diet associated with reduced incidence of Alzheimer’s Disease. Alzheimer’s & Dementia, 11, 1007-1014.

13. Sánchez-Villegas, A., Henríquez-Sánchez, P., Ruiz-Canela, M., Lahortiga, F., Molero, P., Toledo, E., & Martínez-González, M. (2015). A longitudinal analysis of diet quality scores and the risk of incident depression in the SUN Project. BMC Medicine, 13, 197-197.

New Year's Resolutions Worth Making: Week 1 - Sleep

The decision to embark on a New Year’s Detox is a frothy mix of nonsense and lunacy. I discuss why that is – at length – here. The TL: DR version: It’s not a real thing and will do you actual, quantifiable harm. If you want to make a manageable, sustainable improvement in your physical health this year you would be much better off taking 10,000 steps per day (1-2) and maybe delaying your breakfast by a couple of hours(3). So, for those of you who are sufficiently convinced that a ‘detox’ is a giant waste of time, energy and life I offer an alternative health resolution. I’ve compiled a list of the top five things you can do to improve your brain function and mental wellbeing in 2017 (based on non-frothy science) because there is no health without mental health. The fantastic five are: Sleep, diet/nutrition, rest/meditation, exercise, and learning. I was originally planning on creating a top ten but small, incremental changes are the ones most likely to stick so get these under your belt and you will be well on the way to a happier, healthier 2017.


There’s supposed to be something very impressive about getting by with very little sleep. We hear urban legends about highly successful people who require only four or five hours per night. They are described as ‘superhuman’ rather than just ‘different’. Corporate law firms and big banks provide beds in their buildings and newly-qualified and graduate trainees fight it out to demonstrate how productive they can be, how much sleep deprivation they can tolerate.

But there is nothing big or clever about surviving on very little sleep. For people who are not natural short-sleepers (and maybe only 2% of the population are) poor and disturbed sleep is a serious problem. The American Centre for Disease Control and Prevention describes insufficient sleep as an ‘important public health concern’(4). According to a recent YouGov poll only half of people are happy with the amount of sleep that they get(5). Psychologically, we know that poor sleep:

  • Increases risk of depression
  • Impairs decision making, including around risk
  • Makes you more easily distracted
  • Makes you less able to adapt to a situation/adopt new strategies that might be more appropriate to the situation
  • Impairs communication and language skills
  • Makes you less able to control mood/impairs mood stability
  • Impairs insight

It has serious consequences for physical health too and poor sleep is associated with increased risk of obesity and heart disease(6).

For a long time disturbed sleep was seen just as a symptom of depression but more recently researchers have been looking at poor sleep as a causal factor in depressive illness(7-8). This perspective presents us with the opportunity to target sleep disorders as a treatment for depression. So, what can you do?

  • Keep cool – Cooling body temperature is a physiological indicator that it will soon be time to sleep. If your room or bed are very hot this can make it harder to drop off and impair sleep quality (think of those hot summer nights). Use the right tog duvet for the season, and use a quiet fan if you need to. You can also promote this sleep-inducing effect by taking a warm bath about an hour before bed, the cooling of the body once you step out of the bath can help to promote sleep.
  • Step in to the light - We all have a natural sleep-wake cycle that coordinates – based on light-exposure – to the 24hr day/night cycle. This is part of the circadian rhythm. Left to its own devices this cycle can drift slightly; it needs light at the right times of day to stay 'anchored'. Try to get at least 30 minutes of bright daylight in the morning or at lunchtime. A half hour walk after lunch is perfect if you can manage it.
  • Hack your ultradian rhythm - As well as the 24hr rhythm you also have a shorter, 90 min cycle clicking over throughout the day, your ultradian rhythm, and tracking this can help you to identify when is the best time for you to go to bed. The ultradian rhythm is remarkably consistent making it a very useful measure and you can track it by timing your yawns. See the image on this page. At the peak of the wave you are at your most alert and this is a great time to work through your to-do list or focus on a challenging problem. 45 minutes later you are at the trough of the wave, at your most sleepy and most likely to yawn. So, if I yawn at 7pm but it’s too early for me to go to bed, I know that I am likely to be most sleepy again at 8.30pm, 10pm and 11.30pm. I might plan, then to be in bed by 10pm or 11.30pm in order to get to sleep quickly.
  • Put down your phone – Smartphones, tablets and computer screens emit blue light. This is the same wavelength as dawn light, and this is received by the suprachiasmatic nucleus (the brain region responsible for controlling the circadian rhythm) as a message that it is time to wake up, be alert and get active. Try to avoid using these devices for at least 60 minutes before heading to bed, or, if you absolutely must, download an app that can help to filter out the blue light.
  • Make sure the room is as dark and quiet as possible (unless that freaks you out). Think about using eye masks, blackout curtains and ear plugs if you live in or near a noisy environment.
  • Avoid alcohol before bedtime – Although it can promote the initial falling asleep, alcohol disturbs the quality of sleep, preventing your brain from entering the deeper sleep stages.
  • Try not to drink too much before going to bed – I mean just normal drinks here. It seems obvious but a lot of people underestimate how detrimental midnight trips to the loo are to a good night’s sleep. Have a bottle of water by your bedside so you can rehydrate in morning.

Also, remember that here is no magic number. The right amount of sleep is the amount that is enough for you, for you not to feel excessively sleepy during the day. That might be seven hours, that might be nine, we all have different sleep needs. So, work out what is right for you and try to achieve that more often than not.

Next week, the effect of nutrition on brain function. Until then, wishing you a very restful night.




  1. Yuenyongchaiyat, K. (2016). Effects of 10,000 steps a day on physical and mental health in overweight participants in a community setting: A preliminary study. Brazilian Journal of Physical Therapy.
  2. Castres, I., Tourny, C., Lemaitre, F. & Coquart., J. (2016). Impact of a walking program of 10,000 steps per day and dietary counseling on health-related quality of life, energy expenditure and anthropometric parameters in obese subjects. Journl of Endocrinological Investgation, DOI: 10.1007/s40618-016-0530-9.
  3. Horne, BD., Muhlestein, J. B. & Anderson, J. L. (2015). Health effects on intermittent fasting: hormesis or harm? A systematic review. American Journal of Clinical Nutrition, 102, 464-470.
  6. Kecklund, G. & Axelsson, J. (2016). Health consequences of shift work and poor sleep. British Journal of Medicine, 355, i5210.
  7. Chen, Y., Keller, J. K., Kang, J., Hsieh, H. & Lin, H. (2013). Obstructive sleep apnea and subsequent risk of depressive disorder: A population-based follow up study. Journal of Clinical Sleep Medicine, 15, 417-423.
  8. Roberts, R. E. & Duong, H. T. (2014). The prospective association between sleep deprivation and depression in adolescents. Sleep, 37, 239-244. 

What’s wrong with the New Year Detox? Well, pretty much everything.


First published 31 Dec 2015

It’s coming to the end of the Dead Zone, those few structureless days between Christmas and New Year’s where there are no rules. Nobody knows what day it is or what to do (is it still okay to eat mince pies?) We’re off work but there’s nowhere to go because we’re all broke from festive fiscal excess. And that’s not the only extravagance we are left to contemplate. Three solid weeks of unabashed eating, drinking and being merry have left most of us with a little more abdominal insulation than seems fair – we were having such a good time. Now we have a few long days to rub our bellies in forlorn resignation, lamenting our gustatory largesse and making heartfelt, if vague, promises to put it right on the first Monday in January. So, it’s less of a ‘Dead Zone’ and more a kind of alimentary purgatory where the already devoured sins are weighed up against the promises to repent.

Repentance comes in the most puritanical of forms, the January Detox, a month of mass mania and ritual self-flagellation. Bodies are pounded on pavements and vile-tasting shots of medicinal herbs are downed in order for the body to be cleansed. This annual penance for the sins of December results in maybe a few pounds temporarily lost but comes at the cost of a month of your life spent in constant self-loathing, misery and deprivation. This is clearly no way to live but it has become a Hunger Game that we play with ourselves, goaded on by the innumerable media outlets and self-styled gurus looking to cash in on this most harmful annual custom. And it certainly is harmful, both physically and psychologically, and it’s about time that we stopped.

There are so many fundamental problems with the January Detox that, like a chocolate orange, it is better to break it down into chunks.

The Science Problem

The first of many problems with the January Detox is the one that is the easiest to expose: it has absolutely no scientific basis. Unless you are addicted to heroin or have been licking lead pipes and require medical intervention detoxing is not a thing. Year after year doctors and science writers valiantly debunk the myth that your body needs the assistance of juices, gels, patches, enemas, or celebrity endorsed magic water to eliminate waste products. They say things like this:

“Let’s be clear,” says Edzard Ernst, emeritus professor of complementary medicine at Exeter University, “there are two types of detox: one is respectable and the other isn’t.” The respectable one, he says, is the medical treatment of people with life-threatening drug addictions. “The other is the word being hijacked by entrepreneurs, quacks and charlatans to sell a bogus treatment that allegedly detoxifies your body of toxins you’re supposed to have accumulated.”– The Guardian, December 2014 (1)

They present reviews of the available literature and conclude: “To the best of our knowledge, no randomised controlled trials have been conducted to assess the effectiveness of commercial detox diets in humans.” (2) That is to say that there is no good quality evidence that any of this stuff works. Or just ‘no evidence’.

We are reminded that no two manufacturers of detox products or purveyors of detox diets can agree on what a toxin is but we blithely trundle on in the pursuit of purity presumably because the idea of a ‘detox’ performs a wholly different function to the reality of it. I’ll get to that in a bit.

As with many other illusions that we like to keep hold of in the face of objective scrutiny (and we all do at times) the wealth of contradictory evidence is casually dismissed in favour of specious subjective experience. During the annual purge detoxers report experiencing symptoms such as bodily aches, brain fog, cravings, acne, poor sleep and digestive problems all of which are referenced on health and weight loss websites as being signs that you are detoxifying (hoorah!). All of which can be more credibly attributed to inadequate caloric intake and a sudden change in diet (oh, wait…).

But, no big deal, right? So maybe it doesn’t technically do anything, there’s no harm done and maybe it will kick-start some healthy changes, yeah?

The Sustainability Problem

This is where it gets a bit technical (*dusts off A-level biology textbook*). The reason that diets of this kind are indicated for short periods of time is because they are inherently unsustainable. When you drastically reduce your caloric intake below basal metabolic rate (the amount needed to keep the organ systems ticking over) it doesn’t take long for the body to glean that there is something drastically wrong. After about 2-3 days the body’s glycogen (sugar) stores are depleted and metabolism switches to using fat as fuel and the production of ketones that the brain can use for energy. There is still, though, a small sugar requirement. In the absence of dietary carbohydrates these missing sugars are synthesised from the body’s own proteins. The body will begin to break down lean tissue (muscle and organs) because ‘the first priority of metabolism in starvation is to provide sufficient glucose to the brain…Initial sources of protein are those that turn over rapidly, such as proteins of the intestinal epithelium. (3) It is worth knowing then that the cells that line the intestine create a barrier between the contents of the gut (including pathogens) and the rest of the body. Damage to this lining impairs the immune system and exacerbates digestive disorders such as IBS and Ulcerative Colitis (4). In the long term very low calorie diets can cause serious damage to the organs and this is the reason that Anorexia Nervosa is the most deadly psychiatric condition, with death often caused by heart or kidney failure.

Of course I’m not talking here about chronic psychiatric conditions. A detox is only a month, maybe six weeks so the risks of long term damage are low. Except they’re not. A study published in 2011 (5) looked at the long-term effects of short term ‘very-low-energy’ (500-550 calories per day) diets. A year after completing the 8 week diet:

  • Levels of leptin, the hormone responsible for feelings of satiety, were significantly lower than at the start of the study

  • Levels of ghrelin, the ‘hunger hormone’ were significantly higher

  • Peptide YY, an appetite suppressor, was lower

  • Self-reported ratings of hunger, desire for food and urge to eat were higher as were preoccupations with food thoughts

  • Participants expended less energy and felt less full.

So brief exposure to a very low calorie diet resulted in long-term hormonal changes that left the dieters hungrier and more obsessed with food than they had been at the start, increased the likelihood of subsequent weight gain and made it harder to lose the next time. The particular cruelty of this situation is that dieters who regain weight (and 90% of all dieters do) will believe – or worse, be told – that it was their lack of control or the failure of their willpower that is to blame, not the powerful biological adaptations to starvation that were set in motion by the diet/detox in the first place. It is a pernicious lie and it makes me angry. Throw the sense of total failure in to the pot with the misery of feeling hungry and deprived the whole time and the fact that this is no long-term solution becomes self-evident.

The irony is that not only does the body resist restriction but the brain does too. In a paper published in 1975(6) restrained eaters - people who tried to rigidly control what they ate and avoided unhealthy foods – tended to overeat when their guard was down. Unrestrained/relaxed eaters ate to their appetites; they stopped when they were full. Making a food forbidden makes us much more likely to overeat when the opportunity arises.

The Psychological Problems

Perhaps longer lasting than the physical effects are those on the mind and these are the ones that I encounter most frequently, in my consulting room. They are multitudinous but I’ll just hit up the main ones.

The social norms around detoxing - its associations with health, celebrity and ‘instaglamour’ - help to cement the denial and perpetuate the essential illusion: that you are doing something healthy for benevolent reasons. In truth you are not ‘detoxing’ you are ‘crash dieting’. It is not because you want to feel good but because you feel guilty and angry with yourself for overindulging during the festive season. It is a kind of open conspiracy; we all know that ‘detox’ is a code word for ‘crash diet’ but we all nod in silent permissiveness of what could more honestly be called ‘elective starvation’. Somehow the word ‘detox’ seems to soften the edges of extreme dieting. If at any other time of the year (except perhaps before a summer holiday) a friend told you that they were restricting themselves to 450 calories per day you’d worry, think these were desperate measures, tell them it was a bad idea, but in January it’s all good, you wish them well and make a date for drinks in a month’s time. In many ways I would be happier for people to call it what it really is, at least that would be honest. It would be real. And we could address it. As it is ‘detoxing’, ‘cleansing’ and elimination diets are a too often a socially sanctioned cover for disordered eating and eating disorders as is attested by the number of high-profile healthy food bloggers who have admitted to having serious eating disorders (7) and those who haven’t…

Also problematic is that this cycle of binging in December and purging in January (sounding disordered yet?) promotes polarised thinking and behaviour. In CBT this is referred to as ‘all or nothing’ or ‘black and white’ thinking, in psychoanalytic theory it’s known as splitting; the setting up of dichotomous states of mind with no room for moderation or shades of grey. It’s absolute triumph vs total worthlessness, virtue vs sin. It’s the two biscuits that ‘ruin everything’ or the additional pound on the scales that means it is going to be a ‘bad day’. Whilst different therapies use different terms for this phenomenon all are agreed that these kinds of extremes are unhealthy. These harsh attitudes make it impossible to experience self-compassion, a trait that is associated with positive mental health outcomes. People who are self-compassionate are happier, more optimistic and emotionally resilient and less likely to be depressed or anxious (8). Self-compassion isn’t about self-pity or lack of discipline and, interestingly, it can support attempts to eat healthily. A recent study suggests that rigid diets tend to result in overeating and that self-compassion can reduce this tendency.(9)

Another facet of this particular brand of splitting is that detoxes tend to be based on the consumption of foods that either don’t taste good (I’m looking at you, wheatgrass) or don’t taste of anything (two words: Rice. Cakes) strengthening the association between ‘pain and piety’ and pleasure as ‘sin’. Coming so soon after the dietary abandon of December the implication is that eating for pleasure is a bad thing and that one should suffer for health. This is both utterly wrong and incredibly unhelpful, particularly when trying to encourage individuals to eat more healthfully in our currently failing attempts to stem the tsunami of obesity.

Rather than helping dieters to understand their personal relationships with food – including the attitudes to food, weight and body shape in their families, schools, society etc. – the January Detox reinforces the two-headed dietary monster of the ‘one-size-fits-all’ and the ‘quick fix’. It should be common sense that genetically (including the gut microbiome) unique individuals with different food histories would benefit from personalised dietary approaches, and that your relationship with your own body is a life-long partnership requiring ongoing investment. But it’s not, and that’s because the diet industry, media outlets and some lifestyle bloggers (a few well-intentioned, others not so much (10)) continue to perpetuate the myth that if you just try hard enough with this short-term intervention everything will be perfect. This is oversimplification to the point of ridiculousness and aspiration to the point of sadism.

Psychologically speaking health lies elsewhere. Somewhere between nutritionism (just nutrients on a plate) and hedonism (I think I ate the plate) is a place where food choices are a result of self-respect, self-awareness and self-compassion. Not aggression, external rules or desperation. For many of us it is not an easy place to get to; there are many outlets competing over the right to tell you what to eat and how you should feel about yourself and it’s been happening for a long time. I sit with patients who were put on diets in infancy because their mothers didn’t want a ‘fat baby’ or whose fathers mocked their adolescent body shape. These children then went in to competitive school environments where the aesthetic was king. Somewhere in the midst of these interpersonal challenges the media intervenes to let us know what the standard is and just how far short of it we are all falling. It can be an enormous task to clear through the layers of extraneous commandments and the years of social training to get back to a place of trust in one’s own body. Anyone who has fed a young child will have a sense of this. A spoonful of food can be mid-flight to the mouth when the child stops. No, I’m done. There might be pathetic half of a fish finger on the plate and, unless they are encouraged to ‘clear the plate’, it will remain abandoned because s/he knows that they don’t need it and what the body doesn’t need it doesn’t want. Children trust their bodies because they haven’t yet been taught not to. Sadly this state doesn’t last long and for many adults the external noise is so powerfully intrusive that the assistance of a therapist is essential in helping to create the quiet and the confidence to hear themselves again.

For a lot of those embarking on it the January Detox has nothing to do with food. Instead it symbolises a different kind of panic; not about the waistline but about the timeline. The closing of another year and the start of a new one inevitably evokes reflection on how the time was spent and, unconsciously for some, how much we might have left. If in this retrospection we feel we have not done enough, not succeeded enough, we can feel a need for a quick win. We cannot change our careers/improve our relationships/get out of debt in a month but we can lose a stone! Drastically changing the body becomes a substitute for feeling powerless to change other areas of our lives. But whilst our energy is focused on just making it through this juice fast the real challenges remain unchanged and neglected. It’s that reality issue again.

Being aware of what we are eating and, crucially, why is the key to regaining a compassionate relationship with the body and a non-anxious attitude to food and eating. Being mindful of what we are really hungry for (food, comfort, sleep, affection) enables us to make more honest food and life choices. If we ate mindfully throughout the year, including allowing room for the occasional overeating, we would negate the need for radical ‘cleansing’ in January.

The January Detox encapsulates everything that is wrong with the way we think about our bodies, food and eating. It is no way to live and no way to treat someone as important as you.




  2. Klein A. V. & Kiat, H. (2015). Detox diets for toxin elimination and weight management: a critical review of the evidence. Journal of Human Nutrition and Dietetics, 28, 675-686.

  3. Berg JM, Tymoczko JL, & Stryer L. (2002) Biochemistry. 5th edition. New York: W H Freeman.

  4. Coskun, M. (2014). Intestinal Epithelium in Inflammatory Bowel Disease. Frontiers in Medicine, 1, 24.

  5. Sumithran, P., Predergast, L., Delbridge, E., Purcell, K. Shulkes, A., Kriketos, A., & Proietto, J. (2011). Long-Term Persistence of Hormonal Adaptations to Weight Loss. New England Journal of Medicine, 365, 1597-1604.

  6. Herman, C. P., & Mack, D. (1975). Restrained and unrestrained eating. Journal of Personality, 43, 647–660.

  7. Refinery 29 – My Life with Orthorexia.

  8. Neff, K. D., Rude, S. S. & Kirkpatrick, K. L. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 41, 908-916.

  9. Adams, C. E. & Leary, M. R. (2007). Promoting self-compassionate attitudes towards eating among restrictive and guilty eaters. Journal of Social and Clinical Psychology, 26, 1120-1144.

  10. Jezebel – Belle Gibson, blogger who lied about having cancer, just keeps lying.

Millennials, Smartphones and Mentalisation

Human beings are in a perpetual state of conversation and conflict between our ancient biology and the modern world. Physiologically we evolved to enjoy and seek out sweet tastes as these foods (typically fruit and tubers) tended to contain useful amounts of energy and were unlikely to be poisonous. This tendency to sweetness was beneficial in pre-agricultural environments where these foods grew seasonally, had to be foraged and were eaten whole, but our modern, industrial food landscape - in which sugar is extracted from one food and added to another - is associated with the over-consumption of refined sugar, of energy intake outstripping expenditure and, in turn, many of the ‘diseases of a modern life’: metabolic syndrome, Type II diabetes and heart disease.

Similarly, the conflict of our ancient brains – predisposed to identifying risks in the environment and anticipating and simulating future problems – and the stresses of modern life are associated with increased incidence of chronic stress, anxiety and depression.

On Christmas Day 2016 a group of educationalists, authors, psychologists and psychotherapists published an open letter(1) in The Guardian calling for government intervention on the amount of screen time children are exposed to citing risks to children’s self-regulation and emotional resilience. Their concern is that increased screen time comes at the expense of meaningful interactions with caring adults and self-directed outdoor play. I think these concerns are sympathetic and well-founded. It will be important that anecdotal and hypothetical links are also borne out in good-quality research that looks at the relationship between use of screen-based devices and mental wellbeing so that the issues may be addressed effectively.

It occurs to me that one potential casualty of our screen-based lives is mentalisation. Mentalisation is the capacity to consider the contents of one’s own mind. It may also be referred to as ‘reverie’, ‘thinking about thinking’ or metacognition. Think of it as the ability to think about our own thoughts; to be able to answer questions like Why did I do that? What am I feeling? It is the cornerstone of self-awareness and higher cognitive functions such as planning, attention, decision-making, reasoning and problem-solving.

A number of offender management programmes focus on increasing the capacity to mentalise. Often offenders struggle with understanding the motivation for their crimes or seeing a connection between the circumstances and their actions. ‘I don’t know what happened. I don’t know why I did it. It just happened. I wasn’t thinking’. In a more general sense all of therapy can be said to be concerned with increasing self-awareness, whether the question we are asking is ‘What do I want to do with my life? Or ‘Why do I feel so sad?’

Here’s the thing, a huge part of the process of developing the capacity to mentalise is space. It is within the quiet of safe isolation (as opposed to a fearful abandonment or loneliness) that we become aware of the contents of our own minds. One of the reasons that babies and young children become so distressed when separated from their parents is because they have yet to develop object permanence; when mum or dad are out of sight they ‘cease to exist’ and this is incredibly frightening for an infant. With time s/he is able to understand that a) the parent continues to exist in the world even when they are not immediately available and b) the loving relationship also continues. In the physical absence of the parent the developing child can conjure up images and associations of the parent, and can soothe themselves with the knowledge of that parent and the belief that they will return.

The positive trajectory of this process is that the child will become aware of their own feeling states. If the experience could be put in to words it would look something like, ‘I am anxious because mum/dad has gone away. I feel lonely. I am frightened that they will not come back. But they have been away before and they did come back and it was okay. It will probably be fine.’ But this process requires absence. It needs for the child to realise and acknowledge that they are alone before they can consider how they feel about it. It is a psychological function that developed, along with the rest of our minds, in a pre-industrial, pre-technological world. It is my suggestion that ready access to smart phones and tablets impedes this process by ensuring that we never really experience solitude. As soon as we are by ourselves, at the touch of a screen, we can be connected to an infinite number of others, whether that’s friends on Facebook, a group on Whatsapp, or the innumerable anonymous masses on Twitter. We can immerse ourselves in somebody else’s life, either as observer or participant and the pesky reality of our own emotional world can be avoided for a while longer.

I have had younger patients (Millennials, if you will) look at me in genuine confusion when I have asked ‘What goes through your mind when you are not doing anything?’ They are never ‘doing nothing’. And then horror when I suggest that it might be interesting and useful to spend just five minutes doing nothing to see what emerges.

‘What do you mean?’

‘I mean, at some point during the week, I would like you to spend five minutes doing nothing.’

‘No, I can’t do that. No. That sounds awful.’

Part of this ‘Terror of Nothing’ is the result of the well-intentioned but ultimately disastrous insistence on efficiency. We spend so much time manically seizing the day and ‘only living once’ that we risk losing the skill of actually living; of appreciating the moment and being aware of our emotional response to it. We’re so busy working out the best angle for the selfie that we miss the glorious #sunset. But, I think, a large part is that as long as you have a smartphone and 4G you never have cause to be doing nothing. There is no solitude. Whether it’s listening to music, scrolling through a news feed, reading a blog post (ahem!) a distraction is at our fingertips. The modern world is one of constant stimulation, instant gratification and certainty. Suffering from momentary boredom? Play a game! Seen a thing that you like? Order now for next day delivery! Unsure about anything?  Ask Professor Google and be uncertain no more.

The problem with this? The problem is that, in order to live meaningful lives, we need to know ourselves. We need to become familiar with the contents of our minds in quiet moments of solitude. We need to be able to tolerate what emerges there whether it is something we consider pleasant or unwelcome. If it is pleasant, why? If it is unwelcome, what does it mean? And we must be able to tolerate uncertainty. Why? Because that is life. Life is uncertain and vacillating. Whether the ambiguity is about a relationship, a job, our own sexuality, our faith, the truth is that most of the time we are unsure. But the task isn’t to be sure. Certainty is a comforting illusion. The task is to be uncertain and still be able to live; to make choices in the direction of our values. To not be paralysed by fear and ambiguity but to know that, though we are not 100% on this, we are still able to take action in line with a deep knowledge of our own minds, needs and morals.

Our personal devices provide an extraordinary opportunity to improve our lives; connecting people across continents; increasing access to education and employment, to inspiration. But they also have the capacity to distract us from other important internal and external events, like an engaged, meaningful conversation, the innate awe of a beautiful sunset, or thoughtful, purposeful nothing.