Nutritional psychiatry

1. Introduction

Version followed: the SMILES trial dietary-support model (Jacka et al., 2017, BMC Medicine) for how a dietitian-led intervention is delivered, and the clinician practice recommendations in Staudacher, Teasdale, Cowan, Opie, Jacka & Rocks (2025, Australian & New Zealand Journal of Psychiatry) for what non-dietitian mental health clinicians do. Eating-disorder recognition follows NICE NG69 as summarised in the sources.

What it is. Nutritional psychiatry is a research field and clinical framework, not a single psychotherapy. Its core claim, set out in a 2015 viewpoint written on behalf of the International Society for Nutritional Psychiatry Research (ISNPR), is that diet and nutrition should be recognised "as central determinants of both physical and mental health" [source: Sarris et al., 2015]. Felice Jacka (Deakin University) led the SMILES trial and is senior author on the 2015 viewpoint and a co-author of the 2025 practice review; her association with the Food and Mood Centre at Deakin is widely reported [uncertain: not verified].

How change is thought to happen. Improving overall dietary pattern (diet quality) is proposed to reduce depressive symptoms through pathways the authors list as the gut microbiome, inflammation, oxidative stress and HPA-axis function [source: Staudacher et al., 2025]. These mechanisms are candidate explanations, not established ones [source: Staudacher et al., 2025, figure on candidate mechanisms]. Clinically, change is delivered through behaviour change: motivational interviewing, personalised goals and practical skills, with mood improvement reported without weight loss [source: Jacka et al., 2017; Staudacher et al., 2025].

Who delivers it. In SMILES, the dietary intervention was delivered by an Accredited Practising Dietitian (Australia) [source: Jacka et al., 2017]. Staudacher et al. (2025) state that mental health clinicians are "well placed" to raise diet, assess intake, give psychoeducation and support change, and should refer to a specialist dietitian where needed. Individualised dietary prescription belongs to registered or accredited dietitians; the psychotherapist works alongside them [synthesis]. Nutritional psychiatry is not itself a regulated treatment or a licensed product; the regulated element is the dietetic profession, whose registration rules differ by country [uncertain: not verified for each jurisdiction].

Evidence status (attributed).

SMILES (67 adults with moderate to severe depression and poor baseline diet, 12 weeks, diet support vs befriending social-support control): greater improvement on the MADRS and higher remission in the diet arm; the authors call it "preliminary RCT evidence" and say replication is "imperative" [source: Jacka et al., 2017].
Authors' own limitations: participants could not be blinded and advertising described the diet, so expectancy may have inflated the effect; the planned sample was not reached; dropout was higher in the control arm; only people with poor diets were recruited [source: Jacka et al., 2017].
Published critique: Molendijk, Fried and Van der Does (2018, BMC Medicine) argued that recruitment practices and expectation bias may explain the unusually large effect; the SMILES authors replied ("The SMILES trial: an important first step", 2018) that raters were blind, sensitivity analyses held, and later studies largely replicated the finding [source: Jacka et al., 2018 reply; critique details as summarised in that reply; critique's full citation uncertain: not verified].
Independent commentary: a Mental Elf review (Alsaif, 2017) called the trial promising but preliminary, noted the diet arm also received hampers, recipes and materials (possible extra expectancy), and the high contact time (about seven hours) as a feasibility issue; dietary support is an addition to usual care, not a replacement [source: Alsaif, 2017].
Meta-analysis: Firth et al. (2019, Psychosomatic Medicine; 16 RCTs, mostly non-clinical samples) reported reduced depressive symptoms with dietary improvement but no clear effect on anxiety; Firth is quoted that "highly-specific or specialised diets are unnecessary for the average individual" [source: University of Manchester news release, 2019].
Staudacher et al. (2025) note that many trials used self-reported symptoms, general-population samples and short follow-up [source: Staudacher et al., 2025].

Related entries: ketogenic and other metabolic therapies for psychiatric disorders are separate, medically supervised interventions and are not covered here except as a referral question (see the sibling entries in this family) [synthesis].

2. Framework

The sources do not publish a phased psychotherapy protocol; the phases below organise the SMILES delivery model and the 2025 clinician recommendations into a sequence a psychotherapist can follow [synthesis; components sourced as tagged].

Phase 0: Safety screen before any diet talk [synthesis, informed by NICE NG69 summary and Staudacher et al., 2025]

Goal: rule out or identify eating disorders, disordered eating (rigid or restrictive eating), significant unexplained weight change, loss of appetite, pregnancy, youth or older age, and medical conditions with dietary implications (e.g. type 2 diabetes, gastrointestinal disorders, coeliac disease).
Format: part of the ordinary intake or a single focused segment of a session.
Move on when: no red flags, or red flags have been routed (eating-disorder service, GP or dietitian) and the person still wants to discuss food and mood.

Phase 1: Sensitive assessment of eating patterns and context [source: Staudacher et al., 2025]

Goal: understand meal and snack pattern, who cooks, a typical day, nutrition knowledge, beliefs, learning style, work and family constraints, symptom-related barriers (appetite change, cravings, apathy, poor concentration and memory), cost, access and food insecurity, and readiness to change.
Format: one session segment, revisited briefly at later sessions; readiness is reassessed each session.
Move on when: the person has a shared picture of their pattern and barriers and expresses some interest in change.

Phase 2: Psychoeducation and shared decision [source: Staudacher et al., 2025; synthesis for the decision step]

Goal: explain, without stigma, that healthy dietary patterns may help manage depressive symptoms as an adjunct to existing treatment; agree on a route: dietitian referral, therapist-supported small changes, group or telehealth options, or no action now.
Move on when: a route is chosen and consent for any referral or information sharing is documented.

Phase 3: Active change [source: Jacka et al., 2017; Staudacher et al., 2025]

Dietitian route (the SMILES model): about seven individual dietitian sessions over roughly 12 weeks, weekly for the first four and fortnightly for the last three; about 60 minutes each in the trial; diet history first, then motivational interviewing, personalised goals and mindful eating, with written information, recipes and practical supports. Staudacher et al. describe typical initial appointments of about 60 minutes and reviews of 30–60 minutes, and suggest people with low readiness or limited skills may need more sessions, longer support or "restart" options.
Therapist's parallel role: behaviour-change support linked to therapy goals (values, activation, problem-solving, self-compassion), monitoring mood and eating-related warning signs, and collaboration with the dietitian [synthesis].
Move on when: changes have been tried over several weeks and the person can describe what helps and what gets in the way [synthesis].

Phase 4: Maintenance, relapse planning and restart [synthesis; restart idea from Staudacher et al., 2025]

Goal: keep changes going through high-symptom periods (prepared plans, shelf-stable foods), plan for setbacks without self-criticism, and agree how to re-access dietetic support.
Durability beyond three months was unknown in SMILES [source: Alsaif, 2017].

3. Guiding principles

Adjunct, never replacement. SMILES tested diet support added to existing treatment, with participants stable on any medication or psychotherapy [source: Jacka et al., 2017; Alsaif, 2017]. Practical meaning: never frame food change as an alternative to the person's current treatment; any medicine question goes to the prescriber.
Weight-neutral. "A weight-neutral approach is critical"; goals focus on diet quality, not weight [source: Staudacher et al., 2025]. SMILES was not a weight-loss diet and mood improved independently of weight change [source: Jacka et al., 2017; Alsaif, 2017]. Practical meaning: do not set, discuss or praise weight targets; talk about patterns and wellbeing.
Shame-aware sensitivity. People often feel shame about food and weight [source: Staudacher et al., 2025]; NICE asks clinicians to be "sensitive when discussing a person's weight and appearance" [source: NICE NG69 via Medical Dialogues]. Practical meaning: ask permission, use neutral words, avoid "good/bad food" labels.
Screen before you advise. Disordered eating is common among people with mental health problems [source: Staudacher et al., 2025]. Practical meaning: check for eating-disorder signs before any change talk, and do not rely on a screening questionnaire alone [source: NICE NG69 via Medical Dialogues].
Readiness first, reassessed each session. [source: Staudacher et al., 2025] Practical meaning: use motivational interviewing; a "not now" is a valid outcome.
Small, achievable, value-based change. [source: Staudacher et al., 2025] Practical meaning: one concrete behaviour at a time that links to what matters to the person.
Simple, not specialised. Firth is quoted that specialised diets are unnecessary for most people [source: University of Manchester, 2019]. Practical meaning: steer away from restrictive or branded "mood diets".
Stay in scope. Individualised dietary advice is dietetic work [source: Staudacher et al., 2025]. Practical meaning: no meal plans, portion, calorie or macronutrient targets, and no supplement doses from the psychotherapist; refer.
Account for symptoms. Depression alters appetite, cravings, motivation, concentration and memory [source: Staudacher et al., 2025]. Practical meaning: design changes that work on low-energy days.
Address social determinants. Assess food insecurity and adapt recommendations [source: Staudacher et al., 2025]. Practical meaning: problem-solve access and cost before discussing food choices.
Collaborate. Respect the therapeutic relationship and coordinate with dietitian, GP and prescriber [source: Staudacher et al., 2025; synthesis]. Practical meaning: consented, regular information sharing.
Supplements go to the prescriber or GP. International guidelines (WFSBP/CANMAT, 2022) grade nutraceuticals by evidence, and a co-author advises use "under the supervision of a qualified clinician" for more serious conditions [source: Western Sydney University news, 2022]. Practical meaning: the psychotherapist explores interest and routes it; never recommends products or amounts.
Honest about evidence. The field's trials are small or short and expectancy is hard to control [source: Jacka et al., 2017; Staudacher et al., 2025]. Practical meaning: present diet as a reasonable, low-risk adjunct with promising but preliminary evidence, not a cure.

4. Intervention inventory

The inventory has two parts: (A) how the dietitian-delivered intervention is described in the sources, at a descriptive level; (B) the psychotherapist's own interventions. All example language is illustrative wording for this guide, not quoted from the sources. Nothing here is a diet plan; food content is described only qualitatively, as the trial reported it, to help you understand what a client may be working on with their dietitian.

A1. The SMILES dietary-support programme (dietitian-delivered; description only)

Purpose / when used: an adjunctive dietary intervention for adults with a current major depressive episode and poor baseline diet quality, alongside existing treatment [source: Jacka et al., 2017].
How it is delivered (as reported): an Accredited Practising Dietitian delivered seven individual sessions over 12 weeks; the first session took a diet history; later sessions used personalised advice and nutritional counselling with motivational interviewing, goal setting and mindful eating. The "ModiMedDiet" drew on Australian and Greek dietary guidelines; it encouraged more whole grains, vegetables, fruit, legumes, nuts, fish, olive oil and some other whole foods, and fewer "extras" such as sweets, refined cereals, fried and fast food, processed meats and sugary drinks. Eating was not restricted and there was no weight-loss focus. Participants received written information, a food hamper, recipes and meal plans [source: Jacka et al., 2017]. Specific amounts, serve numbers and scoring rules are dietetic content and are deliberately not reproduced here.
Who was excluded in the trial: among others, bipolar disorder, pregnancy, unstable medical illness, severe food allergies or aversions, current diet or exercise programmes, and current substance use disorder; eating disorders are not listed in the trial's eligibility description [source: Jacka et al., 2017]. Do not assume trial findings apply to excluded groups [synthesis].
Control condition: a befriending social-support protocol with the same schedule, covering neutral topics, without psychotherapy techniques [source: Jacka et al., 2017].
Example language (illustrative): "The study most people mean when they talk about food and mood involved seven sessions with a dietitian, alongside people's usual treatment. If you're interested, I can help you find a dietitian who works that way."
Watch for: clients presenting the trial as proof that diet replaces medication or therapy; clients who hear "Mediterranean diet" as a rule set to follow perfectly (a risk sign for rigidity) [synthesis].

A2. Dietetic care in mental health settings (as described in the 2025 practice review)

Purpose / when used: individualised dietary assessment and advice through a structured nutrition care process [source: Staudacher et al., 2025].
How it is delivered (as reported): face-to-face care is generally more effective than web-based care but costlier and less accessible; telehealth helps people with low motivation or agoraphobia, though evidence is weaker; a blended model (face to face first, then video reviews) and group consultations for peer support are suggested [source: Staudacher et al., 2025].
Example language (illustrative): "Some dietitians offer video follow-ups after a first in-person visit. Would that be easier for you on low-energy weeks?"
Watch for: access barriers (cost, waiting lists) that need problem-solving in therapy [synthesis].

B1. Raising the topic with permission

Purpose / when to use: opening a conversation about eating without implying blame; use at intake as part of lifestyle questions, or when the client links food and mood themselves [source: Staudacher et al., 2025 for raising awareness; steps are synthesis].
Steps:
1. Ask permission to talk about everyday habits including eating, sleep and movement.
2. Normalise: many people's eating changes when they are low.
3. Offer choice: "now, later, or not at all".
4. Note the client's own words for food and body and use them.
Example language (illustrative): "Would it be OK if we spent a few minutes on how eating has been going lately? Lots of people find it changes when their mood drops. We can leave it if it's not a good time."
Watch for: visible discomfort, deflection or body-focused self-criticism (slow down and consider B2); relief at being asked (a good opening). Working: the client volunteers detail without apologising for it.

B2. Eating-disorder and disordered-eating screening and caution

Purpose / when to use: before any change talk, and whenever weight, shape or restriction comes up [source: NICE NG69 via Medical Dialogues; Staudacher et al., 2025].
Steps:
1. Hold in mind NICE's indicators for assessment or referral: unusually low or high weight for age or rapid weight loss; restrictive eating; disproportionate concern with weight or shape; compensatory behaviours (vomiting, laxative or diet-pill misuse, excessive exercise); menstrual or endocrine disturbance; unexplained gastrointestinal symptoms, electrolyte problems or hypoglycaemia; difficulty managing a diet-related chronic illness such as diabetes or coeliac disease; atypical dental wear; high-risk activities such as professional sport, dance or modelling [source: NICE NG69 via Medical Dialogues].
2. Remember peak risk in adolescence, but eating disorders occur at any age [source: NICE NG69 via Medical Dialogues].
3. A brief screening questionnaire (NICE names SCOFF) may support, but must not be the sole basis for deciding [source: NICE NG69 via Medical Dialogues]. Do not reproduce or improvise items; use licensed or published versions per your service's policy [synthesis].
4. Weight or BMI alone should not decide whether someone needs help [source: NICE NG69 via Medical Dialogues].
5. If an eating disorder is suspected, refer promptly to an age-appropriate eating-disorder service and involve the GP for physical risk assessment (including effects of malnutrition or purging); identify emergencies where physical health or suicide risk is compromised [source: NICE NG69 via Medical Dialogues].
6. Pause general "healthy eating" work while this is assessed; diet-quality goals can reinforce restriction [synthesis].
Example language (illustrative): "Before we talk about any changes, I want to check something I ask everyone: have you ever felt that food, eating or your weight takes over your thoughts, or felt you have to make up for eating?"
Watch for: enthusiasm for "clean" or rule-bound eating, rapid weight change, secrecy, rising anxiety around meals, food rules framed as mood treatment. Working: the client can talk about food with flexibility and without compensatory urges.

B3. Sensitive assessment of eating patterns

Purpose / when to use: to build a shared, non-judgemental picture before any decision [source: Staudacher et al., 2025].
Steps:
1. Ask open questions: how many meals and snacks in a typical day, whether they cook for themselves, what a typical day looks like, what they know about nutrition [source: Staudacher et al., 2025].
2. Map how eating differs on good and bad days [synthesis].
3. Ask about appetite change and specific cravings, energy, and concentration as they affect shopping and cooking [source: Staudacher et al., 2025 for symptom barriers].
4. Note medication-associated appetite or weight change as information for the prescriber, not something you interpret [synthesis].
5. If useful and safe (no eating-disorder signs), mention that online diet-quality checks exist (the review names a University of Newcastle tool and the CSIRO Healthy Diet Score), and that brief Mediterranean-diet adherence questionnaires are used in research [source: Staudacher et al., 2025].
Example language (illustrative): "Walk me through yesterday, from when you got up — just roughly what and when you ate, no need to be exact. And how does a really low day look different?"
Watch for: shame ("I know it's terrible"), over-precision or calorie talk (possible restriction), chaotic or very limited intake (consider dietitian or GP). Working: the client describes their pattern matter-of-factly and identifies one or two patterns they would like to change.

B4. Barrier mapping

Purpose / when to use: after assessment, to understand what makes change hard [source: Staudacher et al., 2025].
Steps:
1. Explore motivation and readiness, food knowledge and cooking skills, learning style and beliefs, work commitments and family dynamics [source: Staudacher et al., 2025].
2. Explore illness-related barriers: apathy, low motivation, poor concentration and memory, appetite change [source: Staudacher et al., 2025].
3. Explore cost and access (see B5).
4. Write a short shared list of barriers, ranked by how much each gets in the way [synthesis].
Example language (illustrative): "If you wanted to cook more, what would get in the way first — energy, money, time, knowing what to make, or something else?"
Watch for: barriers that are really symptoms of untreated depression (treat the depression first or in parallel); cultural or religious food practices (respect and include) [synthesis]. Working: the client sees barriers as problems to solve rather than personal failings.

B5. Food-insecurity assessment and linking

Purpose / when to use: whenever cost or access may be a barrier; before any food-choice conversation [source: Staudacher et al., 2025].
Steps:
1. Ask directly and without judgement whether there are times when money for food runs short or the person skips meals for that reason [synthesis on wording].
2. Adapt suggestions: low-storage meal strategies, free community meals, community cooking classes [source: Staudacher et al., 2025].
3. Explore subsidised dietetic services and how to access them [source: Staudacher et al., 2025].
4. Link to social work, benefits advice or local food programmes as your service allows [synthesis].
Example language (illustrative): "Some people I see find food costs a real squeeze, especially lately. Is that something that affects you?"
Watch for: embarrassment; housing problems (no kitchen or storage) that make standard advice irrelevant. Working: concrete access steps are in place before any food goals are set.

B6. Psychoeducation on food and mood

Purpose / when to use: after assessment, to give an accurate, non-stigmatising rationale [source: Staudacher et al., 2025].
Steps:
1. Explain that healthy overall dietary patterns may help manage depressive symptoms and that high intake of discretionary foods (e.g. chips, sugar-sweetened drinks) is associated with poorer mental health [source: Staudacher et al., 2025].
2. Give the evidence honestly: promising, mostly small or short trials; works as an addition to treatment [source: Jacka et al., 2017; Staudacher et al., 2025].
3. Emphasise pattern over single foods and that mood can improve without weight change [source: Staudacher et al., 2025; Jacka et al., 2017].
4. Say plainly that specialised or restrictive "mood diets" are not needed [source: University of Manchester, 2019].
5. Check understanding and invite the client's own views [synthesis].
Example language (illustrative): "Research suggests that the overall way we eat — more plants and whole foods, fewer highly processed snacks and sugary drinks — can help mood a bit, alongside treatment. It's not about weight or being perfect, and it doesn't replace what's already helping you."
Watch for: guilt ("so I caused my depression"); all-or-nothing interpretation; requests for a specific plan (route to dietitian). Working: the client restates the idea in their own words, without self-blame.

B7. Motivational conversation about change

Purpose / when to use: when the client is ambivalent; readiness is reassessed every session [source: Staudacher et al., 2025; SMILES used motivational interviewing: Jacka et al., 2017].
Steps [synthesis, following general motivational interviewing practice]:
1. Ask open questions about what the client would like to be different.
2. Reflect both sides of ambivalence.
3. Elicit the client's own reasons, linked to their values (e.g. energy for their children, feeling more in control).
4. Ask about confidence and what would raise it.
5. Summarise and ask what, if anything, they want to do next; accept "not now".
Example language (illustrative): "Part of you would like to eat more regularly, and part of you feels it's one more thing you can't manage right now. Both make sense. What would make it feel even slightly more doable?"
Watch for: the therapist arguing for change (backs off); compliance without ownership. Working: change talk comes from the client and goals are in their words.

B8. Small, value-based behaviour goals (therapist-supported)

Purpose / when to use: once the client is ready, for change that does not need individualised dietary prescription [source: Staudacher et al., 2025 for small, achievable, value-based change].
Steps:
1. Choose one behaviour, not a nutrient or weight outcome (e.g. adding one familiar plant-based food the client already likes, or eating something within a set time of waking). The review's example is adding legumes once a week [source: Staudacher et al., 2025].
2. Link it to a value the client named (B7) [source: Staudacher et al., 2025; synthesis on linking].
3. Make it specific: when, where, what first step, what to do if the plan fails [synthesis].
4. Rate confidence; shrink the goal until confidence is high [synthesis].
5. Review next session with curiosity, not grading [synthesis].
6. Hand off anything requiring amounts, food substitutions for medical conditions, or meal structure to the dietitian [source: Staudacher et al., 2025 on referral; synthesis].
Example language (illustrative): "What's one small thing you'd like to try this week that fits with wanting more energy for your kids? Let's make it small enough that you could do it even on a rough day."
Watch for: goals drifting into rules, counting or "cutting out" foods (return to B2); perfectionism; self-criticism after a lapse. Working: goals are met most days without distress and the client starts proposing the next step.

B9. Planning for high-symptom periods

Purpose / when to use: for clients whose eating collapses during low phases [source: Staudacher et al., 2025].
Steps:
1. Identify what eating looks like in the worst weeks (B3).
2. Use the review's practical strategies: shopping with lists, batch-cooking on better days, keeping long-shelf-life foods at home for high-symptom periods [source: Staudacher et al., 2025].
3. Fold these into the client's existing relapse-prevention or behavioural-activation plan [synthesis].
4. Plan help from others (shared shopping, a friend cooking) where available [synthesis].
Example language (illustrative): "When you're flat and can't face cooking, what could already be in the cupboard so that eating something is the easy option?"
Watch for: plans that assume energy the client doesn't have; plans that cost more than the budget allows (B5). Working: on a low week, the client reports using the plan rather than skipping meals.

B10. Working with cravings and emotional eating

Purpose / when to use: when cravings (sweet, salty, fatty) or eating to cope are prominent [source: Staudacher et al., 2025 notes food-specific cravings as a symptom-related barrier and suggests craving-matched alternatives].
Steps:
1. Explore the function of the craving or eating episode (soothing, energy, reward, habit) with ordinary functional analysis [synthesis].
2. Widen the coping repertoire for the emotion itself (soothing, contact, activity) as part of therapy [synthesis].
3. Where the client wants food alternatives, the review gives examples of satisfying swaps that match the craving type (e.g. yoghurt with fruit or nuts for sweet cravings; olives or nuts for salty cravings) [source: Staudacher et al., 2025]; individual swaps are best worked out with the dietitian [synthesis].
4. Avoid forbidding foods; restriction can intensify cravings and binge cycles [synthesis].
Example language (illustrative): "When the urge for something sweet hits in the evening, what is it doing for you? Let's look at what else could do some of that job, without banning anything."
Watch for: loss-of-control eating, bingeing or compensatory behaviour (B2, refer). Working: urges are noticed earlier and responded to with more choice.

B11. Mindful eating (therapist version)

Purpose / when to use: SMILES included mindful eating in the dietitian sessions [source: Jacka et al., 2017], but the trial description available does not detail how it was taught [uncertain: not verified]. The therapist version below is general practice, for clients who eat on autopilot or with no awareness of hunger and fullness [synthesis].
Steps [synthesis]:
1. Agree to try one meal or snack a day with fewer distractions.
2. Before eating, notice hunger, mood and thoughts for a few breaths.
3. Eat with attention to taste and texture, without judging.
4. Afterwards, notice how body and mood feel; jot a word or two if useful.
Example language (illustrative): "This isn't about eating less or more — just noticing. For one snack a day, could you put the phone down and see what you notice?"
Watch for: use of mindfulness as a tool to restrict or override hunger; heightened body-checking in people with eating-disorder history (do not use, or use only with eating-disorder specialist input). Working: the client reports more awareness and less guilt around eating.

B12. Referral to a registered or accredited dietitian

Purpose / when to use: whenever individualised advice is needed, and always in the review's referral groups [source: Staudacher et al., 2025].
Steps:
1. Refer if any of these apply: eating disorder or disordered eating (rigid or restrictive eating); poorly managed comorbidity; loss of appetite; significant weight change; specialised dietary needs; young, pregnant or elderly; gastrointestinal disorders; type 2 diabetes [source: Staudacher et al., 2025].
2. For a suspected eating disorder, refer to an eating-disorder service rather than general dietetics (B2) [source: NICE NG69 via Medical Dialogues].
3. Before referring, assess readiness, motivation and red flags [source: Staudacher et al., 2025].
4. Explain what a dietitian does and does not do (individualised advice, not "a diet"); discuss cost, subsidised options and telehealth [source: Staudacher et al., 2025; synthesis on wording].
5. With consent, send a brief referral covering diagnosis, current treatment and prescriber, mental-health barriers and any eating concerns [synthesis].
Example language (illustrative): "A dietitian is the right person to tailor this to you — they look at your whole situation, including your health, budget and what you like to eat. Would you like me to help with a referral?"
Watch for: fear of being judged or put on a diet (address directly); referral to unregulated "nutritionists" or sellers of supplements (check credentials) [synthesis]. Working: the client attends and reports the dietitian's advice felt doable.

B13. Collaboration with dietitian, GP and prescriber

Purpose / when to use: throughout active change [source: Staudacher et al., 2025 on dietetic care respecting the therapeutic relationship; steps are synthesis].
Steps [synthesis]:
1. Obtain consent for two-way information sharing.
2. Agree roles: dietitian sets dietary advice; therapist supports motivation, emotion and behaviour; GP or prescriber manages medical issues and medicines.
3. Share relevant observations: mood change, appetite or weight change the client mentions, signs of disordered eating, side effects the client reports.
4. Pass medication-related appetite or weight concerns to the prescriber; never advise changing a medicine.
5. Keep messages consistent; check with the client how the plans fit together.
Example language (illustrative): "You mentioned your appetite has gone up a lot since the new tablets. That's worth telling your doctor about — would you like me to mention it in my letter too?"
Watch for: conflicting advice between professionals; the client feeling monitored. Working: the client can describe one shared plan.

B14. Conversations about supplements and nutraceuticals

Purpose / when to use: when the client asks about, or already takes, supplements for mood [source: Western Sydney University, 2022 on WFSBP/CANMAT guidelines; steps are synthesis].
Steps:
1. Ask non-judgementally what they take or are considering, and why [synthesis].
2. Explain that international guidelines (WFSBP and CANMAT, 2022) graded many nutraceuticals and plant medicines: some were recommended or provisionally recommended as adjuncts for particular disorders, others had mixed evidence or were not recommended [source: Western Sydney University, 2022].
3. Say that safety, interactions and product quality are medical questions and route them to the GP, prescriber or pharmacist; a guideline co-author advises supervision by a qualified clinician for more serious conditions [source: Western Sydney University, 2022].
4. Do not recommend a product, brand or amount [synthesis].
Example language (illustrative): "Some supplements have been studied for mood, with mixed results, and some interact with medicines. That's a really good question for your doctor or pharmacist — shall we write it down for your next appointment?"
Watch for: stopping prescribed treatment in favour of supplements (raise with prescriber promptly); high spending on products; St John's wort and other agents with interaction risk being taken without the prescriber's knowledge [synthesis]. Working: the prescriber knows everything the client takes.

B15. Questions about ketogenic or other metabolic diets for mental illness

Purpose / when to use: when a client asks about ketogenic or "metabolic psychiatry" diets [synthesis].
Steps [synthesis]:
1. Acknowledge the interest and that this is an active research area.
2. Explain that such diets are medical interventions that need supervision by a doctor and a dietitian, particularly with psychiatric medicines, diabetes, pregnancy or eating-disorder history.
3. Screen for eating-disorder risk (B2); restrictive regimens are a particular concern.
4. Route to the prescriber or GP; see the sibling entries in this family for that literature.
Example language (illustrative): "That's something being researched, but it's a big medical change, not a lifestyle tweak. It would need your doctor and a dietitian on board. Would you like to raise it with them?"
Watch for: self-started restrictive diets, rapid weight loss, dizziness or other physical symptoms (urge GP review). Working: the decision is made with medical input.

B16. Group, peer and remote options

Purpose / when to use: for clients who would benefit from peer support or cannot attend in person [source: Staudacher et al., 2025].
Steps:
1. Offer or signpost group consultations or cooking classes [source: Staudacher et al., 2025].
2. Consider telehealth or blended dietetic care for low motivation or agoraphobia, noting weaker evidence [source: Staudacher et al., 2025].
3. In therapy, prepare for group anxiety and plan the first attendance [synthesis].
Example language (illustrative): "There's a community cooking group nearby. Would it help to plan how you'd get there the first time?"
Watch for: comparison and body talk in groups (risky for some clients) [synthesis]. Working: attendance continues and the client reports feeling supported.

B17. Maintenance, relapse planning and restart

Purpose / when to use: after a period of change, and at the end of dietetic contact [source: Staudacher et al., 2025 on restart options; steps are synthesis].
Steps [synthesis]:
1. Review what changed, what helped and what mood effects the client noticed.
2. Identify early signs of slipping (skipped meals, more takeaway during low weeks).
3. Add these to the client's relapse-prevention plan with B9 strategies.
4. Agree how to re-access the dietitian if needed.
5. Frame lapses as expected and as information, not failure.
Example language (illustrative): "If things slip in a hard month, what would be the first sign, and what's the one thing you'd go back to?"
Watch for: self-criticism after lapses; loss of all gains when therapy ends. Working: the client can describe their own restart plan.

5. Handling problems

The sources mainly address readiness, barriers, food insecurity, weight stigma and referral; most responses below are synthesis and are marked as such.

Shame and defensiveness when food is raised. People often feel shame about food and weight [source: Staudacher et al., 2025]. Response: name it gently, return control ("we can leave it"), drop evaluative words, and focus on how eating fits their life rather than what is "wrong" [synthesis]. Illustrative: "I'm not here to judge what you eat. I'm curious how it's connected to how you feel."
Low readiness or "I can't think about this now". Readiness is reassessed every session [source: Staudacher et al., 2025]. Response: accept "not now", record it, and come back later; treat the depression first; keep any step tiny [synthesis].
Stuck: goals agreed but nothing happens. Response: check whether the goal was the client's or yours; shrink it; look for symptom barriers (apathy, memory, appetite) and use prompts, ready-to-eat options and support from others; consider more sessions or a restart with the dietitian, as the review suggests for low readiness or limited skills [source: Staudacher et al., 2025 for more sessions or restart; rest synthesis].
Non-adherence to dietitian advice. Response: explore what got in the way without blame; with consent, tell the dietitian what is not working so advice can be adapted; never alter their advice yourself [synthesis].
Overwhelm ("there's too much to change"). Response: return to one behaviour; postpone everything else; emphasise that small changes count and perfection is not needed [synthesis; small changes from Staudacher et al., 2025].
Emerging restriction, rigidity or eating-disorder signs during the work. Response: stop goal-setting, assess using NICE indicators, involve the GP for physical risk, and refer to an eating-disorder service if suspected; do not continue general healthy-eating work in parallel without specialist agreement [source: NICE NG69 via Medical Dialogues for indicators and referral; rest synthesis].
Client wants weight loss as the goal. A weight-neutral approach is recommended and mood improvement can occur without weight loss [source: Staudacher et al., 2025]. Response: acknowledge the wish, explore what weight loss would mean to them, offer behaviour and wellbeing goals instead, and refer weight or medical concerns to the GP or dietitian [synthesis].
Medication-related appetite or weight change. Response: take it seriously, record it, and pass it to the prescriber with consent; explore distress about it in therapy; never suggest stopping or changing the medicine [synthesis].
Client wants to replace medication or therapy with diet. SMILES tested diet as an adjunct [source: Jacka et al., 2017]. Response: explain this plainly, explore the wish (side effects, stigma, wanting control), and support them to discuss it with their prescriber [synthesis].
Supplement or influencer enthusiasm. Response: explore interest, explain that evidence varies by agent [source: Western Sydney University, 2022], and route safety and interaction questions to the GP, prescriber or pharmacist; discuss cost and marketing claims critically [synthesis].
Food insecurity or no cooking facilities. Response: practical access first (community meals, low-storage strategies, subsidised dietetics, cooking classes) [source: Staudacher et al., 2025]; link to social or benefits support; do not set food goals the client cannot afford [synthesis].
Rupture (client feels lectured, judged or monitored). Response: name the possibility, apologise for any judgement conveyed, ask what felt off, and re-agree whether and how food is discussed; separate the dietitian's advice from the therapy relationship if needed [synthesis].
Cultural, religious or family food practices. Response: build changes within the client's food culture; involve family when they shop or cook, with consent; ask the dietitian for culturally appropriate advice [synthesis].
Severe mental illness, bipolar disorder, pregnancy or young age. SMILES excluded bipolar disorder and pregnancy [source: Jacka et al., 2017], and the review lists young, pregnant and elderly people for dietitian referral [source: Staudacher et al., 2025]. Response: do not generalise the trial to these groups; work with the treating team and dietitian [synthesis].
Physical warning signs (fainting, rapid weight loss, persistent vomiting, very limited intake). Response: same-day GP or urgent medical review as appropriate; NICE identifies emergencies where physical health is compromised [source: NICE NG69 via Medical Dialogues; rest synthesis].
Suicide or self-harm risk surfacing. Response: follow your standard risk assessment and safety-planning procedures; eating-disorder assessment includes checking for self-harm and suicide risk [source: NICE NG69 via Medical Dialogues; rest synthesis].
Client disappointed that mood has not changed. Response: revisit expectations honestly (preliminary evidence, modest and variable effects), review the overall treatment plan with the team, and keep the dietary changes that the client values for their own sake [synthesis; evidence status from Jacka et al., 2017 and Staudacher et al., 2025].

Sources

Sources:

Papers and guidelines cited:

Jacka FN, O'Neil A, Opie R, Itsiopoulos C, Cotton S, Mohebbi M, et al. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial). BMC Medicine, 15, 23. https://doi.org/10.1186/s12916-017-0791-y. Trial registration ACTRN12612000251820.
Jacka FN, O'Neil A, Itsiopoulos C, Opie R, et al. (2018). The SMILES trial: an important first step. BMC Medicine, 16.
Molendijk M, Fried E, Van der Does W (2018). The SMILES trial: do undisclosed recruitment practices explain the remarkably large effect? BMC Medicine [uncertain: not verified; content known only as summarised in the authors' reply].
Sarris J, Logan AC, Akbaraly TN, et al., Jacka FN, on behalf of the International Society for Nutritional Psychiatry Research (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271–274. https://doi.org/10.1016/S2215-0366(14)00051-0
Firth J, Stubbs B, et al. (2019). The effects of dietary improvement on symptoms of depression and anxiety: a meta-analysis of randomized controlled trials. Psychosomatic Medicine [full citation uncertain: not verified; summary from university news release].
Staudacher HM, Teasdale S, Cowan C, Opie R, Jacka FN, Rocks T (2025). Diet interventions for depression: Review and recommendations for practice. Australian & New Zealand Journal of Psychiatry, 59(2). https://doi.org/10.1177/00048674241289010
Sarris J, et al. (2022). WFSBP and CANMAT taskforce clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals. World Journal of Biological Psychiatry [full citation uncertain: not verified; summary from university news release].
National Institute for Health and Care Excellence (2017). Eating disorders: recognition and treatment (NG69) [recommendations cited from a secondary summary; check the current NICE version].

Not verified: details of the Food and Mood Centre's current programmes and resources, and ISNPR's current activities beyond its authorship of the 2015 viewpoint [uncertain: not verified].

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