What comes to your mind when you hear the acronym TLC? For some (especially healthcare professionals), the first thought is "Tender Loving Care". But for me, as a researcher in mental health, it stands for Therapeutic Lifestyle Changes. I was first introduced to this term as a Master’s student in Developmental Psychology, and I have been intrigued to understand more ever since.
I am a Research Assistant in Perinatal Psychiatry at the SPI Lab. Through the articles I write for Inspire the Mind, I aim to uncover the evidence base to support novel therapeutic interventions. In my previous pieces, I have discussed Play Therapy and Mindfulness for Childhood ADHD.
What is the concept of Therapeutic Lifestyle Changes?
For a few decades now, the benefits of exercise, a multi-nutrient diet, and spending time in nature have been discussed in the field of mental health.
The concept of Therapeutic Lifestyle Changes (TLCs) was popularised in mental health research through a landmark paper in 2011, by Dr Roger Walsh. As the name suggests, this concept refers to making positive changes to one’s lifestyle for the benefit of overall mental health and well-being.
The article highlights factors such as "exercise, nutrition and diet, time in nature, relationships, recreation, relaxation, and stress management…" as some of the most prominent TLCs. In this article, Dr Walsh also talks about the fact that there is evidence to show that the effects of TLCs are comparable to the impact of psychotherapy and medication for certain types of mental health conditions. What's more, studies in this field of research have investigated the impact of TLCs across various groups and age groups, from young children with neurodevelopmental conditions to veterans experiencing psychiatric symptoms.
In today’s article, I will talk about some of these aspects, and the research evidence supporting them.
Are nutritional and dietary changes associated with mental health?
The gut-brain axis has been frequently investigated in mental health research, and studies have since looked at understanding how nutrition and diet can have a positive impact on mental health.
In his article, Dr Walsh discusses the benefits of a "pesco-vegetarian" and "rainbow diet", integrating multicoloured fruits and vegetables, as well as fish such as salmon, which is high in omega-3 fish oils.
Dietary interventions and their impact on mental health have been widely studied all over the world. For example, the 2017 SMILES trial investigated the efficacy of 7 individual nutritional consulting sessions for 12 weeks, and results found that the group receiving dietary support had significant improvements in depressive symptomology by the end of this intervention, after the 12 weeks.
Being a "flexitarian" (someone who prefers to mostly eat vegetarian foods while occasionally consuming meat), I have been curious about the Mediterranean diet, which is mentioned by Dr Walsh in the article, and has been investigated in the context of mental health. Among the most recent is a 2019 study investigating the impact of a Mediterranean diet and fish oil supplementation on self-reported depressive symptoms. Three months after the intervention, the group receiving Mediterranean diet cooking workshops and fish oil supplements reported improvements in ‘mental health quality of life’ and reductions in self-reported depressive symptoms.
With my research interest in perinatal mental health (that being mental health during pregnancy and for 12 months after), I came across a 2022 study looking at Mediterranean Diet adherence and mental health during pregnancy. Interestingly, results showed that greater adherence to the diet, with higher consumption of nuts, olive oil, fruits and vegetables, and reduced intake of red meat, was associated with lower levels of anxiety and improved overall mental health and well-being. Through my reading of the benefits of this diet, I will now go to my Pinterest board dedicated to healthy eating and add some exciting recipes to try this weekend!
Do time in nature, recreation and enjoyable activities positively impact mental health?
One of my New Year’s Resolutions has been to do an off-screen activity every evening when I get back from work. While this isn’t always the case, I have noticed that on days when I read a book or listen to a podcast, I’m more relaxed and fall asleep quicker. Of course, what also helps in the summer months is living 10 minutes away from a park, for after-work evening walks.
These three aspects, time in nature, recreation, and enjoyable activities, have been identified as among some of the prominent TLCs, and there is no scarcity of evidence supporting their benefits (you can also find more information about the healing power of nature-based therapy in a previous article for ITM here).
The benefits of immersion in nature have been investigated in the context of various mental health problems like stress and depression. More notably, a 2009 study investigated the role of walks in the park on symptoms of childhood ADHD (Attention Deficit Hyperactivity Disorder). Results found that 20 minutes of walking in the park was sufficient to elevate levels of concentration and attention performance, as compared to walks in downtown regions and participants’ neighbourhoods. In a 2021 systematic review specifically looking at nature-based interventions for mental and physical health, results from 50 studies showed that nature-based interventions like gardening, nature-based therapy, and "green exercise" (physical exercise in natural environments) were associated with improvements in mental health outcomes in adults.
We’ve spoken about the benefits of nature, but what about the effects of recreational activities and their evidence base?
The breadth of recreational types is wide, and their effects on mental health and well-being have been widely investigated (for example, you can read an ITM article about the therapeutic benefits of poetry here).
One aspect I found particularly interesting in Dr Walsh’s article was the mention of the benefits of humour as a recreational activity. In a 2019 meta-analysis synthesising the efficacy of laughter/ humour-based interventions (with 10 trials, and 814 participants), results found that engaging in these interventions led to improvements in sleep quality, and decreases in the levels of mental health problems like depression and anxiety. In terms of the content of these interventions, they included comedy movies, laughter yoga, and humour skills training.
In another 2020 study conducted among military veterans with Post Traumatic Stress Disorder (PTSD), a group recreational intervention with outdoor activities (such as equine care, angling, falconry, and archery) led to reductions in PTSD, depression, and anxiety scores, both after the intervention and at a 4-month follow-up.
Conclusions: Are TLCs truly beneficial?
The studies that I have spoken about today are just the tip of the iceberg in this specific field of research. Trials have investigated numerous TLCs across different populations, and most of them provide evidence supporting their efficacy. What I particularly find interesting about TLCs is that they can all be integrated into our daily routines. Whether it be through changes in diet, spending more time in nature, or getting enough physical activity, they can together become a part of our lifestyle. Further, these changes aren’t large changes that will significantly impact our routines. They can gradually be incorporated into our lifestyle, for the betterment of our well-being and mental health.
Lastly, and from an implementation point of view, the evidence for TLCs is powerful. The ease with which they can be used as adjuncts to psychotherapy, medication, or any other form of intervention provides plenty of potential to integrate them into evidence-based practice for mental health and well-being.