CHPR: Please tell us how you got interested in the field of lifestyle psychiatry.

Dr. Noordsy: Early in my career, I was part of a community treatment team that worked with young people in the early stages of substance use and psychosis. We wanted to help them find rewarding activities that could compete with the alcohol, cannabis, or whatever else they were using so they’d be more motivated to stay sober. Many had enjoyed team sports or other physical activities in their school years, so we incorporated physical activities into their treatment plan to help them cultivate new sources of joy in their lives. I certainly don’t want to oversell our interventions, as only about a quarter or a third of the patients took to an exercise intervention. But for them, it made a significant difference in reducing their substance use and improving their psychosis and cognitive functioning. Cognition is the domain of symptoms that’s most associated with functional impairment, and as these patients’ cognition improved, they were able to go back to school and get jobs and form social relationships and function better. I myself am a regular runner and passionate about the benefits of physical exercise, and I was so inspired by the improvements we saw in these patients. I began organizing grand rounds and symposia together with colleagues who were doing research in the field, and my involvement in lifestyle psychiatry grew from there.

CHPR: Lifestyle interventions, like exercise and healthy eating, have been reported to help a range of psychiatric disorders. How compelling are the research findings?

Dr. Noordsy: I’ve been following this literature for about 25 years and have been impressed with how strong the evidence has become. The data are getting to be as strong or stronger than we see with some of our pharmacologic interventions or our psychotherapies. For example, after patients participate in exercise programs—typically ranging from six weeks to six months—we see improvements in cognitive function and mood across several populations, including the healthy aging population, people with depression, and people with schizophrenia (Noordsy D. Lifestyle Psychiatry. Washington, DC: American Psychiatric Association Publishing; 2019). And for people with mild cognitive impairment, exercise is probably the most effective intervention for protecting against the development of full-blown neurocognitive symptoms.

CHPR: What does the research show about the effects of exercise on schizophrenia?

Dr. Noordsy: Exercise is arguably the strongest intervention we have for improving cognition among people with schizophrenia. This is particularly important as we have no pharmacologic treatments for the cognitive symptoms of schizophrenia spectrum disorders. Exercise also leads to increases in the volume of specific regions of the brain, like the hippocampus, at least partially reversing brain volume reductions long observed in people with schizophrenia. There are also improvements in Positive and Negative Syndrome Scale scores, particularly on the subscale that measures negative symptoms, like social withdrawal, amotivation, and blunted affect. However, the positive symptom subscale typically shows less improvement in response to exercise interventions (Firth J et al, Early Interv Psychiatry 2018;12:307–315).

CHPR: What does the research show about the effects of exercise on other disorders, like anxiety disorders?

Dr. Noordsy: In anxiety disorders, we see some desensitization from arousal responses, probably because as people exercise, they associate elevated heart rate and elevated respiration with a calming effect as opposed to fear. For PTSD, there’s been some interesting work using exercise to enhance the effects of exposure therapy, as well as evidence of improvements in anxiety, mood, sleep, and hyperarousal domains (Crombie KM et al, J Anxiety Disord 2023;94:102680). And there is some evidence that exercise reduces inattentive symptoms in adolescents with ADHD and reduces cravings in people with substance use disorders, but the literature is not as strong for these diagnoses.

CHPR: What are the biological reasons for why exercise benefits mood and cognition?

Dr. Noordsy: Exercise is linked with elevations in levels of BDNF (da Cunha LL et al, J Affect Disord 2023;326:73–82). BDNF stands for brain-derived neurotrophic factor, and it keeps brain cells healthy and helps maintain connections between neurons. It plays an important role in learning, memory, and overall brain plasticity, and its deficiency is associated with several neurological and psychiatric disorders, including mood and psychotic disorders and Alzheimer’s disease. Over the past decade, there’s been a growing body of evidence that inflammation contributes to neurodegenerative changes that underlie several psychiatric disorders and that neuroprotective interventions are likely to be helpful. Some of the medications we use, like lithium, elevate BDNF and have neuroprotective and even neurotrophic effects (Ghanaatfar F et al, Fundam Clin Pharmacol 2023;37(1):4–30). Just to be clear, “neurotrophic” refers to substances that promote the growth and development of brain cells.

CHPR: So higher BDNF levels are associated with lower rates of inflammation as well as with neuroprotective effects?

Dr. Noordsy: That’s correct. We want to reduce levels of inflammation in the brain and increase levels of neurotrophic factors like BDNF. And besides exercise, other lifestyle interventions like yoga, meditation, and traditional diets like the Mediterranean diet—which minimizes processed foods and red meat—also exhibit anti-inflammatory properties and may be linked to increased BDNF levels.

CHPR: How do you integrate these lifestyle interventions in your practice?

Dr. Noordsy: We have started a lifestyle psychiatry clinic at Stanford where we offer holistic care that includes lifestyle interventions delivered by psychiatrists, psychologists, and a health and wellness coach. These interventions complement usual psychiatric and psychological treatments, like individual and group psychotherapy and pharmacologic care. We get a careful history on nutrition, physical activity, stress levels, sleep patterns, and substance use, and then make recommendations for each of those areas. We ask patients to set goals with us, so if we identify that they’ve become very sedentary, we set goals around getting physically active. When the person comes back for their next visit, they may report that they only exercised a quarter as much as they had set a goal for. So, we focus on how they felt after exercising and let the lifestyle change promote itself based on the effects the patient experienced afterward. In most cases, it’s a bit of a lightbulb moment for patients, where they say “Oh yeah, you’re right! When I went out for a walk that one time, I felt energized and calmer afterward.”

CHPR: Is there a minimum amount of exercise that we should recommend to patients?

Dr. Noordsy: Most studies have examined 30–60 minutes of exercise, two to three times a week, primarily as this is most practical to supervise. There is a general finding that greater exercise intensity and duration is associated with greater benefit, but once you get to about three hours a week of exercise, the benefit for mood effects seems to level out. More vigorous exercise produces greater benefits for mood, although there aren’t good studies looking at different types of exercise (for example, strength training versus aerobic exercise). The data show that both aerobic and resistance exercise have benefits for mood and cognition, although some studies show that different domains of cognition may be more responsive to aerobic versus resistance training. So, there could be complementary benefits, but that literature is still very much in its infancy. And almost all the literature is based on solitary exercise, like going on treadmills and stationary bikes. That’s just what’s easy to do in a lab. So, there’s still a lot we need to learn—not only comparing the benefits of team sports versus solo exercise, but also looking at the effect of being out in nature versus in a gym.

CHPR: On the inpatient psychiatric unit where I work, patients are often reluctant to join the exercise groups. Do you have any suggestions for how to motivate them?

Dr. Noordsy: I used to work in inpatient care, so I understand what you’re describing. One thing I suggest is to tell patients that fatigue is a common symptom in many psychiatric disorders. Our bodies tell us that when we’re fatigued, we should rest, but resting won’t help us feel better—it’ll just keep us stuck. Unless we’ve just engaged in considerable physical exertion, resting when we feel fatigued only makes that fatigue deeper. We need to be active to overcome fatigue. Inactivity begets inactivity. There have been some inpatient-based studies of the effect of exercise on patients’ outcomes. A psychiatric unit affiliated with the University of Vermont did a remodel to create a nice exercise area and then conducted an open-label study that showed significant improvement in measures, either the GAD-7 or PHQ-9, in patients who participated in the exercise compared to those who didn’t (Tomasi D et al, Glob Adv Health Med 2019;8:1–10). But I think the lifestyle interventions we provide hospitalized patients often leave much to be desired. If we could feed patients a Mediterranean-style diet and give them access to vigorous exercise during their stay on the psychiatric unit, they might experience the positive benefits of these lifestyle changes and gain the motivation to adopt these habits when they go home.

CHPR: Besides improving outcomes, can lifestyle interventions help patients improve on lower doses of medication? This would certainly help with side effects.

Dr. Noordsy: Yes, often patients come to our clinic and they’ve been on, say, a selective serotonin reuptake inhibitor. They’ve gotten better, but they’ve got sexual side effects, or they feel numb, and they’d like to not experience those side effects anymore. I tell them “I can certainly taper your dose, but let’s try to put some lifestyle behaviors in place so they can help you to stay in remission or get more fully into remission so that we can scale back your meds to the least necessary dose.”

CHPR: When you’re able to get patients to adopt healthy behaviors, are there lasting benefits even if they don’t continue the healthy behaviors over the long term?

Dr. Noordsy: Unfortunately, a consistent finding in the literature is that the benefit of an exercise intervention decays quickly over the course of the following three to six months unless people keep doing the exercise. So, the best exercise intervention is one that somebody will stick with, and the best nutritional intervention is one that somebody will follow consistently. A big part of our work is to help patients build habits that they can own and sustain, like daily ­meditation practice, eliminating soda, or walking the stairs rather than using an elevator. Once individuals establish consistent habits, they gain lasting advantages because regular exercise, for example, can lead to epigenetic changes—meaning changes in gene expression—that upregulate BDNF production in the long term. As a result, people who exercise consistently experience ongoing ­benefits.

CHPR: Wow. It would be helpful if hospital discharge planning included signing patients up for an exercise program at a local gym or meeting with a nutritionist.

Dr. Noordsy: I know some colleagues in Australia who’ve told me they have a program where patients can get six sessions a year with an exercise physiologist. The program was originally designed for patients with diabetes or cardiovascular issues, but the folks in psychiatry are using it to connect patients to exercise trainers. They can also refer patients to regular sessions with a nutritionist. We have an infrastructure issue here in the US, right? We make referrals that will lead to insurance-covered billable services, so we tend not to make referrals for exercise, nutritional plans, meditative activities, yoga, that sort of thing. But in our Stanford Lifestyle Clinic, we do make those recommendations for our patients. Giving written prescriptions for exercise can help some patients adhere to the recommendations (Editor’s note: For a sample exercise prescription, see: www.thecarlatreport.com/exerciserx).

CHPR: Some patients, particularly those with cardiovascular disease, may face risks of adverse outcomes, like myocardial infarctions, from vigorous exercise. How do you screen patients to determine their suitability for exercise prescriptions?

Dr. Noordsy: My approach to lifestyle interventions, including exercise, is more of a collaborative conversation than a strict prescription. I begin by educating patients on how exercise, alongside nutrition and meditation, can impact their psychiatric condition, discussing both the benefits and the limitations of current evidence. For those interested in incorporating exercise into their recovery, we set realistic goals based on their current activity levels and any health risks, like cardiovascular disease. It’s crucial to start where they’re most likely to succeed, gradually building toward more ambitious targets. Vigorous exercise, introduced properly, can not only reduce the risk of further cardiac incidents but also aid in managing conditions like type 2 diabetes. However, if a patient’s medical condition is unstable, I prioritize safer interventions like medication, healthy eating, and meditation, postponing exercise until it’s deemed safe. Collaboration with other medical professionals involved in the person’s care is essential.

CHPR: I wonder if psychiatrists in general are starting to adopt these recommendations more widely.

Dr. Noordsy: I’m impressed with the level of interest I’ve seen in lifestyle psychiatry. I think that in the past, providers saw lifestyle interventions as helpful but not essential. We’re increasingly convincing providers that, since we want our patients to have the best outcomes, we should routinely incorporate lifestyle changes into our treatment plans.

CHPR: Thank you for your time, Dr. Noordsy.