Chapter 156
Promoting Mental Health — 4
There is a digital intervention to promote sleep quality that has been getting more intensive study in randomized trials and large real-world assessment: digital cognitive behavioral therapy (dCBT). Interactive dCBT can be accessed through mobile apps or computers and tailored to the individual, exploring the background factors, providing education, collecting data, reducing stimulation, and overall coaching for sleep pattern improvement. The American Academy of Sleep Medicine reviewed more than fifteen apps. Some are available free, like CBT-i Coach, while others require a prescription and are FDA cleared, such as Somyrst (available through Nox Health). Direct randomized comparison of the digital alternative to in-person psychotherapy CBT for improving sleep suggests the former may approximate the latter, but it is far more practical and much less expensive.
Continuing this discussion in the lifestyle+ dimension, we’ve long known about the relationship between physical activity and mental health, including consistent reduction of anxiety and depression, but that was all reinforced by the largest systematic review of over two hundred randomized trials of over fourteen thousand participants with depression. The results, as summarized below (fig. 11.3), showed significant improvement with walking and jogging, yoga, all forms of aerobic exercise (including dancing and cycling), strength training, tai chi, and qigong. Notably, the most common form of medical treatments—selective serotonin reuptake inhibitors (SSRI)—were barely effective, much weaker than exercise. CBT, as mentioned for promoting sleep health, had a similar magnitude of impact as many types of physical activity. The intensity of exercise was correlated with the extent of improvement, but low-intensity walking and yoga had meaningful benefit.
Figure 11.2. Factors affecting sleep health (upper panel) and potential interventions (lower panel). Adapted from Nicholas Meyer et al., “The sleep–circadian interface: A window into mental disorders,” Proceedings of the National Academy of Sciences of the USA 121, no. 9 (2024): e2214756121, https://doi.org/doi:10.1073/pnas.2214756121.
Those findings are further strengthened by a meta-analysis of forty-one randomized controlled trials of exercise for a major depressive disorder that markedly reduced symptoms of depression. Even light exercise such as gardening led to improvement, and, independent of type of physical activity, one of every two individuals experienced reduced symptoms, somewhat more than what is seen with medications or psychotherapy.
In a study of the mental health benefits of exercise with more than fifty thousand participants, including a subset that underwent brain imaging, physical activity reduced stress-related neural activity in the amygdala and reduced cardiovascular risk. Participants with and without depression benefited, but the ten-year cardiovascular risk showed a more striking reduction in people with depression. Besides improvement in mood and reduction of cardiovascular risk that occurs with regular exercise, a recent study indicates that physical activity mitigates social isolation and loneliness.