Top Recommendations for Brain Health as we age:
- Physical exercise – both aerobic and resistance training
- Healthful nutrition – fresh, fibrous whole foods
- Cognitive engagement – educational achievement and continued engagement in cognitively challenging and meaningful activities
The Stanford Lifestyle Psychiatry Clinic offers holistic psychiatric care, psychotherapy, nutritional counseling, medication management, mind-body practices, and health-and-wellness coaching. The clinic is different from other psychiatric facilities in that it offers lifestyle interventions (including exercise, nutrition, yoga, mindfulness, and sleep optimization) as primary modalities for mental health management, in addition to medication and psychotherapy.
“The clinic is for patients who prefer to take an active role in their healing by adding lifestyle practices to their treatment plan, rather than take the passive route of just taking medication,” says Douglas Noordsy, Founder and Director of the Stanford Lifestyle Psychiatry Clinic. “Patients should be interested and motivated to implement lifestyle practices in their daily life to acquire skills they can continue to use to take responsibility for their mental health.”
The clinic also offers rising mental health care professionals opportunities to train in lifestyle psychiatry and incorporate lifestyle interventions into medicine at Stanford and worldwide.
Focusing on Collaboration
Care in the Lifestyle Psychiatry clinic begins with a comprehensive assessment of past and current behaviors related to the patient’s health and well-being. The health provider identifies which behaviors may have contributed to the patient’s mental health symptoms and offers treatment options that may include medications, psychotherapy, and lifestyle interventions.
The provider then collaborates with the patient to review the potential advantages and disadvantages of a menu of lifestyle interventions. Together, the provider and patient create a treatment plan that sets manageable goals and promotes healthy behaviors. With ongoing sessions, the provider and patient continually revise the plan until the patient achieves the desired results.
“When working with patients, we offer a menu of lifestyle interventions, and they choose which option they would like to use,” says Dr. Noordsy. “With this shared decision-making approach, patients are more engaged and have a greater sense of ownership regarding their health. I’ve found that when lifestyle interventions are part of the treatment plan, patients feel more confident about managing their mental health and are likely to achieve better outcomes.”
Faculty at the clinic investigate various lifestyle practices to discern which are most effective for specific psychiatric conditions. For example, research shows that physical exercise results in increased brain activity by signaling neurons to form synapses (connections among brain cells). Also, brain imaging reveals that regular exercise causes critical areas of the brain to grow larger in volume. Increasing brain activity and volume is particularly supportive for those with schizophrenia and bipolar disorder.
“Neurotrophic factors released during exercise tell your brain, ‘It’s time to wake up; we are out of hibernation and into activity mode.’ This increased activity in the brain is especially beneficial for people with bipolar and schizophrenia who have impairment in the activity of certain parts of the brain as well as loss of brain volume,” says Dr. Noordsy. “Also, brain regions grow larger due to physical exercise, and a larger brain is healthier whether or not you have a brain disorder.”
Lifestyle Psychiatry and Depression
To treat depression, Dr. Noordsy explains that taking a standard antidepressant medicine could help decrease depression faster than a lifestyle intervention such as exercise but may not be effective over time. Also, patients often experience a flatness of emotion and sexual side effects from antidepressants.
Physical exercise is typically on the treatment plan for patients with depression because it releases neurotransmitters involved with mood and well-being, such as dopamine, norepinephrine, and serotonin. Although physical exercise may take longer to decrease symptoms of depression, this intervention has a more lasting effect. Additionally, exercise positively affects fatigue, cognitive function, heart health, and overall health.
“When lifestyle interventions are effective, patients often reduce the dose of their medication and sometimes come off of it entirely. This can be an ideal way to minimize medication side effects,” says Dr. Noordsy. “Ultimately, if a patient’s desired outcomes are a greater sense of well-being and greater ability to function in the world, then lifestyle interventions are the best way to get there.”
For some patients, their symptoms are so severe that they struggle to adopt lifestyle interventions such as regular exercise or optimal sleep without using medication. In these cases, Dr. Noordsy prescribes an antidepressant to get them moving. Over time, as the amount of exercise, healthy nutrition, and mindfulness practice increase the patient may get to a point where symptoms are manageable and they can decrease medication dosage to minimize side effects.
Yoga and Mind-Body Practices in Psychiatric Care
Along with psychiatrists, the clinic’s team of providers includes a health-and-wellness coach and two psychologists trained in Stanford’s therapeutic yoga program, YogaX, which aims to bring yoga and mind-body practices into healthcare. With a full range of expertise, the clinic provides multidisciplinary care across the pillars of Lifestyle Medicine.
YogaX instructors are trained psychologists who promote the science and application of therapeutic yoga. YogaX offers yoga teacher training tailored to healthcare providers who want to bring yoga practices and philosophy to their patients. YogaX also provides free yoga and wellness classes for the public on its YouTube channel.
In the future, Dr. Noordsy will continue to train mental healthcare professionals in the value and application of lifestyle medicine in psychiatry. In this training, he emphasizes the importance of educating patients about the research behind the recommendations. For example, he believes that if patients know about the evidence-based mental health benefits behind the yoga intervention, they are more likely to engage in a regular yoga practice.
“I’d love to see the day where every psychiatrist offers lifestyle interventions as part of their treatment plan,” says Dr. Noordsy. “Whether it’s a weekly yoga group, eating salads for lunch, or taking daily walks in nature, seeing their psychiatrist for regular care is just one of many things the patient is doing for their well-being.”
***For more information or to schedule an appointment at the Stanford Lifestyle Psychiatry Clinic, please call (650) 498-9111.
By Mary Grace Descourouez, MS, NBC-HWC
Binge-watching television, watching YouTube videos for hours, or scrolling on your phone every morning may seem harmless, but research shows that too much screen time may be detrimental to your health.
We know children’s brains are affected by spending too much time glued to their cell phones, however research shows that adult brains are also negatively impacted by excessive screen time, defined as more than two hours a day outside of work hours.
Too much screen time can impact our health in a myriad of ways, from eye strain and neck pain to social isolation and mental health, and in some cases, it may cause harm to our brains.
“The negative effects of screen time are insidious because you can’t see what’s happening in your brain as you’re staring at the screen,” says Maris Loeffler, MA, Family and Marriage Therapist, member of the Stanford Lifestyle Medicine Cognitive Enhancement pillar. “If you scrolled on your phone in bed for an hour just one morning, the negative impacts would be minimal. But if it becomes a habit, day after day, month after month, this behavior can take a toll.”
Since the eyes are directly connected to the brain, Loeffler encourages us to think about our eye health to ensure overall brain health. Rather than looking at our phones upon waking, Loeffler recommends starting each morning looking at the horizon or an object outside and far away.
To prevent eye strain throughout the workday, The American Academy of Ophthalmology recommends the 20-20-20 rule for adults who work on a computer. This rule suggests that individuals look at something 20 feet away for 20 seconds every 20 minutes of the day.
What is Happening in the Brain During Screen Time?
This study found that increased use of screens among adults may harm learning, memory, and mental health, as well as the potential to increase the risk of early neurodegeneration. The study shows that in adults aged 18 – 25, excessive screen time causes thinning of the cerebral cortex, the brain’s outermost layer responsible for processing memory and cognitive functions, such as decision-making and problem-solving.
Another study found that adults who watched television for five hours or more per day had an increased risk of developing brain-related disease like dementia, stroke, or Parkinson’s.
This study found that excessive screen time can hinder sleep, especially when looking at screens late at night. Light from the screen can delay melatonin release from the brain’s pineal gland, impacting the body’s natural circadian rhythm and causing difficulty sleeping.
Additional studies found that adults who engage in excessive screen time or have a diagnosed smartphone addiction had lower gray matter volume. Gray matter is brain tissue essential for daily human functioning and is responsible for everything from movement to memory to emotions. Gray matter volume naturally decreases as we age, so along with reducing screen time, engaging in activities that maintain our gray matter volume and promote brain health, such as exercise and movement, restorative sleep, social engagement, and stress management, is crucial.
“Passive screen time is like eating sugar but for your brain. It ‘tastes’ good, and you want it now, but you’re not actually feeding yourself. You’re not giving your brain any nutrition,” says Loeffler. “Instead, replace screen time with an intentional healthy habit that feeds your brain in a healthy way. Lifestyle medicine activities, like exercise, good sleep, social connection, and stress management, function like ‘nutrition’ for your brain and mental health.”
Specifically, Loeffler cautions us not to pick up the phone after the alarm goes off in the morning. She explains that looking at our email or social media on our phones while still in bed jolts the nervous system and can trigger the fight-or-flight response since we aren’t fully awake yet.
Also, if we look at our phones first thing every morning, we create a pattern and can set the flight-or-flight response as our default mode of operation. So, not only does this behavior set an anxiety-filled tone for the day, but we are also training our brains to be more hypervigilant in general.
“One of the biggest issues with picking up the phone right away in the morning is that when you have an object close to your face, it’s registered as a threat,” says Loeffler. “You wouldn’t want to wake up and look a bear in the face every morning. On a physiological level, it’s the same thing.”
Practice of the Month: No Screen Time for the First Hour of the Day
Stanford Lifestyle Medicine experts recommend no screen time for the first hour of the day to support cognitive enhancement. Instead, we suggest engaging in a lifestyle medicine activity upon waking to promote whole-body health:
- Exercise
- Call a friend or family member
- Prepare a healthy breakfast
- Meditate and count your blessings
- Listen to music
- Create a gratitude list
- Read a book
- Spend time outside and get morning light
“How do you want your day’s energy and mood to start?” says Loeffler. “Intentionally implementing a morning routine that reflects lifestyle medicine choices instead of screen time sets a positive tone for the day and supports brain health and cognitive enhancement.”
In recent years, a groundbreaking field known as Metabolic Psychiatry has emerged at the intersection of metabolic and brain health. Spearheaded by Shebani Sethi, MD, a Clinical Associate Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, this innovative field sheds light on the powerful connection between our metabolic health and mental well-being.
As rates of mental illnesses like Alzheimer’s, bipolar disorder, and schizophrenia rise alongside metabolic conditions such as obesity, diabetes, and cardiovascular disease, researchers are uncovering how these seemingly distinct issues may be intertwined. A Stanford study found that developing a metabolic disorder like insulin resistance can double your risk of depression, even if you’ve never experienced mental illness before. As such, emotional and metabolic disorders often occur together, with over forty percent of individuals with severe mental illnesses also experiencing metabolic syndrome.
It’s easy to see how mental illness could lead to conditions such as obesity or diabetes because someone struggling emotionally might be unable to eat well or exercise. However, it’s becoming increasingly apparent that metabolic disorders have a distinct role in the onset and progression of mental illnesses.
“Many psychiatric diseases have underpinnings in metabolic dysfunction,” explains Dr. Sethi. “We are seeing insulin and glucose handling differences in the brain in patients with psychiatric conditions.”
These metabolic issues in the brain are present even at the early stages of disease detection and progression. Dr. Sethi explains that patients diagnosed with a first episode of schizophrenia—before any treatment with medications—already show disrupted energy metabolism in the brain. Similarly, Alzheimer’s disease has been referred to as type III diabetes due to its strong link to disrupted insulin signaling in the brain.
Dr. Sethi has been a trailblazer in this area since 2015, founding the first academic Metabolic Psychiatry Clinic focused on treating patients with both mental health and metabolic disorders. Metabolic Psychiatry examines how improving metabolic health through nutritional interventions can significantly enhance brain health and mitigate the symptoms of severe psychiatric conditions.
How Metabolic Health Impacts Brain Health
Many psychiatric diseases are characterized by metabolic dysfunctions, which impair the brain’s ability to function properly. These dysfunctions occur when chemical processes are disrupted, hindering the body’s ability to produce and utilize energy efficiently.
A well-known example is insulin resistance, where the body’s cells don’t respond appropriately to insulin—the hormone that allows glucose to enter cells and be metabolized for energy. The brain, one of the most metabolically active organs, requires large amounts of energy to function. It is highly dependent on glucose due to its limited flexibility to use other energy sources. This dependence makes metabolic conditions like insulin resistance particularly harmful, as any disruption in glucose supply puts the brain at risk for cognitive decline and neuronal degeneration.
“If you don’t have optimal metabolic functioning in the brain, then you won’t process and create energy as efficiently as a healthy brain,” states Dr. Sethi. “The brain will have all this glucose around it, but you can’t actually use it properly. This is called cerebral glucose hypometabolism, and it’s very common in psychiatric and neurodegenerative diseases.”
Other metabolic abnormalities commonly seen in psychiatric conditions include oxidative stress, mitochondrial dysfunction, and neurotransmitter imbalances, which all have downstream effects on synapse connection and neuronal excitability.
“We don’t know for sure what the primary drivers for these metabolic dysfunctions are, but it is likely a combination of factors influencing one another,” says Dr. Sethi. “For example, insulin resistance is correlated with higher inflammation levels and oxidative stress in the brain, which in turn exacerbates mitochondrial and neurotransmitter dysfunction.”
Chronic inflammation disrupts brain activity and undermines the integrity of the brain’s protective mechanisms. The blood-brain barrier (BBB), a critical structure that protects the brain from harmful substances in the blood, becomes compromised. This “leaky” BBB allows inflammatory molecules, pathogens, and toxins to enter the brain from the bloodstream, exacerbating the inflammatory response within the brain and creating a self-perpetuating cycle of neuroinflammation. “We see significantly more inflammation in the brains of people with mental illness, especially in treatment-resistant patients, than in healthy people,” states Dr. Sethi.
How Nutrition Can Improve Brain Health
Dr. Sethi’s metabolic approach to brain health not only enhances our understanding of psychiatric conditions but also opens up new avenues for treatment, such as nutritional interventions. Studies have shown that nutritional interventions can impact the balance of neurotransmitters in the brain, which is crucial for regulating mood and behavior.
By targeting metabolic dysfunctions such as insulin resistance, oxidative stress, and improper energy utilization, nutritional interventions can help restore brain function and reduce inflammation. This comprehensive approach addresses the symptoms of psychiatric conditions while tackling their underlying causes, offering a more effective and holistic treatment strategy.
The Stanford Metabolic Psychiatry group, led by Dr. Sethi, is investigating whether dietary changes, such as adopting a ketogenic diet, can stabilize brain health. The ketogenic diet, which is high in fat and low in carbohydrates, encourages the brain to use fat and ketone bodies as primary fuels instead of glucose. This metabolic shift helps counteract issues related to glucose metabolism and insulin resistance. The diet adopted in the study focuses on consuming whole, unprocessed foods, including protein and non-starchy vegetables, without restricting fats.
“The ketogenic diet is a strong, powerful metabolic intervention. It can improve neurological and psychiatric conditions by making changes in the brain through these pathways,” says Dr. Sethi. “By providing ketones as an alternative energy source, the ketogenic diet reduces glucose dependency, which is beneficial in counteracting glucose hypometabolism.”
In Dr. Sethi’s study among participants with schizophrenia consuming a ketogenic diet, there was a 32 percent reduction in Brief Psychiatric Rating Scale scores. There was also increased life satisfaction and enhanced sleep quality among participants.
The ketogenic diet can also have a positive influence on brain aging for everyone and has been experientially understood to help normalize the brain for centuries. Dating back to roughly 500 BC, fasting (which mimics the ketogenic diet) was used to treat epilepsy. Current research shows that the destabilization of brain networks might indicate early signs of reduced metabolism, which is linked to dementia. By increasing the use of ketones for energy, dietary interventions like the ketogenic diet can provide more energy to the brain and potentially protect against aging-related cognitive decline.
Dr. Sethi warns, however, that “the ketogenic diet is very specific and may not be suitable for everyone. It can be incredibly beneficial for people with insulin resistance, obesity, or diabetes, but it may not be feasible or appropriate for all individuals.”
Future studies will reveal further dietary interventions that benefit brain health. For example, Dr. Sethi and her team plan to conduct a randomized controlled trial with the ketogenic diet versus the Mediterranean diet in cases of serious mental illness. Whichever diet one chooses, Dr. Sethi recommends the reduction of sugar, ultra-processed foods, and refined carbohydrates to promote both metabolic and brain health.
“Our diet provides the precursors for neurotransmitters and other vital cellular structures in the brain, while also impacting inflammation levels. If we have deficiencies in our diet, we’re not going to be able to create the components and environment we need for optimal brain function and regulation of mood,” states Dr. Sethi.
Stanford psychiatrist Douglas Noordsy, MD, is a physician who literally walks his talk. For the last 40 years, he has woken up at 6 a.m., drank a glass of water, and gone for a run, often with his dog.
“Living a healthy lifestyle has always been an integral part of my life. I share lifestyle interventions [such as daily exercise] with my patients because these practices have worked for me,” says Dr. Noordsy, Head of the Stanford Lifestyle Medicine Cognitive Enhancement pillar.
As a practicing psychiatrist for more than 35 years, editor of the book Lifestyle Psychiatry, and founder of the Stanford Lifestyle Psychiatry Clinic, Dr. Noordsy has played an integral role in incorporating lifestyle medicine into traditional psychiatry care. Dr. Noordsy’s research interests at Stanford include medication and the impact of exercise and nutrition for individuals with schizophrenia and bipolar disorder. He is currently Director of the Lifestyle & Sports Psychiatry special initiative in the Department of Psychiatry.
“With lifestyle psychiatry, clinicians utilize three methods of care—psychotherapy, medication, and lifestyle interventions,” he says. “This three-pronged approach helps us to be more effective physicians, and patients have a better chance at achieving their best outcomes.”
Northeastern Roots
Doug Noordsy always knew he wanted to be a physician. Initially thinking he would go into primary care, he shadowed his family’s doctor as a high school student in Syracuse, New York. As an undergraduate, he took pre-med courses at St. Lawrence University, a small liberal arts college in upstate New York.
“In my junior year, I took the ‘Introduction to Psychology’ course and I fell in love with it,” he says. “I was particularly interested in those with significant disorders such as schizophrenia—I was intrigued by how they thought. So those early experiences drew me into psychiatry.”
In the 1980s, he attended medical school at Washington University in St. Louis, Missouri. During this time, neuroscience and psychopharmacology were becoming more advanced, which led to debate among mental healthcare professionals about the relative merits of pharmaceuticals over psychotherapy.
“We learned about psychotherapy and medication, but lifestyle medicine wasn’t on the table at that time,” says Dr. Noordsy. “There was discussion about the importance of social support, but we didn’t consider how other aspects of lifestyle affected mental health, such as exercise, nutrition, and mind-body practices.”
After completing his residency at Dartmouth-Hitchcock Medical Center in New Hampshire, he served as a Professor of Psychiatry at the Geisel School of Medicine for 25 years. At Dartmouth, he was also the Director of Psychosis Services and an Investigator in the Psychopharmacology Research Group.
“At Dartmouth, there was an emphasis on treating patients in a collaborative, recovery-oriented way rather than a paternalistic approach,” says Dr. Noordsy. “It was important in my early development to be trained in a model of care that was respectful of the wishes and preferences of the patient.”
Leading a Movement
Dr. Noordsy was ahead of his time regarding the connection between lifestyle medicine and mental health. As a medical school student, he managed his own mental health using lifestyle practices such as daily exercise, healthful nutrition, and quality sleep. He found benefit with these practices and shared them with his patients.
“At first, I was shy about sharing my experiences because they weren’t evidence-based at that time. It’s counter-academic to share things with patients from your own life that are not supported by clinical trials,” he says. “But over time, the evidence caught up.”
Indeed, over the last 15 years, research on lifestyle medicine has shifted the narrative from personal anecdotes to gaining attention and respect within the medical community. Specifically, Lifestyle Psychiatry has moved from something psychiatrists recommended softly to valid, evidence-based medicine.
In the fall of 2015, Dr. Noordsy came to Stanford to join the Department of Psychiatry & Behavioral Sciences, which was building a team for student-athletes. Many of the athletes wanted to minimize medication exposure, so he continued to recommend lifestyle interventions as options to support their mental health.
In 2019, Dr. Noordsy coined the term “Lifestyle Psychiatry” by publishing a book with that title. This book is a curation of research from around the world detailing the evidence on lifestyle practices in psychiatry. In 2020, he opened the Stanford Lifestyle Psychiatry Clinic. In 2024, the president of the American Psychiatric Association (APA) promoted lifestyle interventions as a core component of psychiatric treatment, bringing this approach into the mainstream.
In his 35-year career, Dr. Noordsy has been a member of the Schizophrenia International Research Society, the International Early Psychosis Association, the American College of Lifestyle Medicine, and a fellow of the APA. He received the Exemplary Psychiatrist Award from the National Alliance on Mental Illness in 2001 and the Excellence in Leadership Award from the Stanford Department of Psychiatry and Behavioral Sciences in 2018.
Although Dr. Noordsy is a nationally acclaimed psychiatrist, his most significant source of pride is his influence on how psychiatric care is delivered. For severe disorders, psychiatry has had a long history of authoritarian care in some settings. With lifestyle psychiatry, where patients choose from a menu of lifestyle practices as part of their treatment plan, the care model shifts from “the doctor knows all” to one where the psychiatrist collaborates with their patients, respects their wishes, and takes a whole-person approach.
“What I’m most proud of is being part of a movement toward empowering and engaging patients to participate in their own health and well-being, rather than just be compliant to their doctor’s instructions,” says Dr. Noordsy. “I’m proud to be part of a new approach to care that promotes mental health by fostering relationships, savoring nutritious meals, and experiencing the beauty of nature at sunrise.”