TCPR: How do you help people see that there is more to mental health than medication?
Dr. Ramsey: People want treatments that aren’t stigmatized, and that’s where I got started with “mental fitness.” We automatically think about “physical fitness” in our culture—independent of medical health—and that’s how I see mental fitness. People really light up when talking about their connection, or their engagement with their work, or feeling a sense of purpose.

TCPR: Can you walk us through the nine tenets?
Dr. Ramsey: The first is self-awareness. I ask people to schedule some time to sit with the self. In this age of constant stimulation, it’s really easy to stop paying attention to yourself: where you are, who you are, what’s new about your life, what you’re struggling with. Journaling improves depression, executive functioning, and ­working memory (Guo L, Br J Clin Psychol 2023;62(1):272–297; Yogo M et al, Br J Health Psychol 2008;13(Pt 1):77–80). When we put words around a problem, it settles us down so we can talk about it. Self-awareness is the backbone for the other tenets because it’s hard to make changes if you’re not aware of what you are doing and how it’s affecting you.

TCPR: What’s next?
Dr. Ramsey: Nutrition. The majority of Americans don’t eat enough of the fruit, vegetables, fish, and fiber they need. So we can often accomplish a lot by sticking to the basics. That is what they did in the trials that compare dietary counseling to active controls like supportive counseling in depression. When patients shifted to a Mediterranean-style diet, their depression improved, and the effect size was moderate to large. Even a brief intervention works, as when they taught the diet through a 13-minute video. I may not focus on nutrition if patients have an eating disorder as a primary diagnosis, but for other patients I’ll open up the subject by asking about their relationship with food, what they are eating, and whether they have food security or not. The next tenet is movement (Francis HM et al, PLoS One 2019;14(10):e0222768; Bizzozero-Peroni B et al, Nutr Rev 2025;83(1):29–39).

TCPR: You mean exercise?
Dr. Ramsey: It is important to call it movement and not exercise. To treat depression, people need about 15–40 minutes a day of light aerobic exercise like brisk walking (Tian S et al, J Psychiatr Res 2024;176:384–392). I worked with one patient where I had no success in getting her to exercise, but she came back one day—beaming—and had picked up dancing. I had no idea. I’d never asked her whether she liked to go dancing. Now, I’ll start with “What types of movement do you enjoy? Do you ever play sports? When do you find yourself happiest with your body?” 

TCPR: What comes after movement?
Dr. Ramsey: Sleep. I start with education, emphasizing the science of sleep and how it enhances neuroplasticity and learning. It is where the brain connects loose ends and flags important memories for long-term storage. I learned about the glymphatic system writing this book, the brain’s waste removal system. We talk about the internal forces behind sleep—sleep drive, which increases the longer you are awake, and circadian rhythm, the cellular cycles that are triggered by light and darkness. Sleep drive is fueled by adenosine, and caffeine shuts adenosine down, so people aren’t going to sleep well if they drink caffeine in the afternoon. Likewise, light at night interferes with the circadian rhythm by decreasing melatonin production. After sleep, I focus on connections.

“Depression makes it hard to prioritize, so I’m going to keep it simple and stick to interventions that are most effective. Movement and sleep hygiene are simple steps with big returns in depression.” 

Drew Ramsey, MD

TCPR: Tell us about that.
Dr. Ramsey: This is getting more important in the age of social media. One in four Americans has exactly zero friends they can confide in. I ask people to take an accounting of their connections. Who can you be close to and vulnerable with? Are there communities where you can be of service rather than be served? Social connections are associated with the kinds of changes that help depression—higher brain-derived neurotrophic factor, lower inflammation, and greater diversity in the gut microbiome.

TCPR: What comes next?
Dr. Ramsey: Engagement. This is about being mentally active—learning, building, and refining cognitive abilities. Our brains like a good challenge, whether solving a jigsaw puzzle or diving into a best-selling book. This may be automatic in our profession, but a lot of people feel like they are going through the motions, and getting back into a stimulating hobby can be low-hanging fruit. I also look for activities that serve a dual purpose. Mentoring or tutoring serve both engagement and connection. Walking with friends in nature serves movement, connection, and our next tenet: grounding.

TCPR: Is that about nature?
Dr. Ramsey: Yes. Grounding tries to address the “nature deficit disorder,” as a British research group calls it, that is common today. Our nervous system evolved in a natural environment, and your brain acts differently when it’s surrounded by green space. In the forest we breathe phytoncides that improve immunity and negative air ions that lift depression (Perez V et al, BMC Psychiatry 2013;13:29). A 90-minute walk in the woods reduces ruminative thinking and dampens the default mode network, while a similar walk in the city or suburbs does not (Bratman GN et al, Proc Natl Acad Sci U S A 2015;112(28):8567–8572). I talk with patients about everyday exposure—like putting plants in their office or taking breaks outside—and more intentional immersion like a hike or a swim. 

TCPR: And tenet #8?
Dr. Ramsey: Unburdening. Most of us keep our traumas held very closely or buried deep. It is certainly hard to open up and engage with trauma. Part of mental fitness is working through and processing those traumatic events, especially if they are clearly blocking relational or professional function.

TCPR: Finally, what is tenet #9?
Dr. Ramsey: The last tenet is purpose. When people feel a sense of purpose, their mental health is better and they live longer. People with a sense of purpose are active and feel like they are in the world for a reason. Purpose is great mental health medicine!

TCPR: How do you describe mental fitness to patients? 
Dr. Ramsey: A lot of times we focus on what is going wrong, but I start with what patients are getting right. I ask about their sleep hygiene, exercise, community support, social connections, sense of purpose, and nutrition. Then I’ll look for what is missing, and bring it up in gentle ways when appropriate. If they are in the midst of mania or severe depression, it’s likely not the right time to bring up a pesto recipe or self-reflective journaling. I try to meet people where they are, and frame mental fitness as opportunities and aspects of life that we all agree impact our mental health.

TCPR: How do you phrase that?
Dr. Ramsey: “I see you’re really isolated these days, and I hope in our work together, we can think about the types of connections that are meaningful to you.” When I say “connections,” it doesn’t always mean close relationships. People can also feel connected to community groups, mentors, art, and religion. A lot of patients don’t know what their passion is, and telling them to find it doesn’t really hit home. Instead, I find it more relatable to help understand what gives them a sense of fulfillment, a sense of calm. We explore what they enjoy—and not just in a hedonistic way, but in a way that is gratifying on a deeper level as a human being. For one patient with depression, it was singing lessons. For another, it was making simple recipes for her family.

TCPR: A lot of patients are familiar with these tenets. How do you make them practical? 
Dr. Ramsey: First, naming them brings them into focus and helps people give themselves credit for what they are already doing. I’ll also share the evidence—a lot of people know that nutrition helps the brain, but they don’t know how big the effect is. (Editor’s note: Shifting to a Mediterranean-style diet had a large effect size compared to supportive interventions in three randomized trials (Jacka FN et al, BMC Med 2017;15(1):23).) Next, I’ll work with them to create goals around areas where they’d like to see improvement. 

TCPR: This is collaborative work.
Dr. Ramsey: Yes! That is something psychiatrists do well, and patients are great partners in this. I look for goals that are realistic and achievable. I don’t want them to do all nine tenets every day of the week. Too often, wellness advice can leave people feeling overwhelmed, misled, and paralyzed.

TCPR: How do you do this work during active depression?
Dr. Ramsey: Depression makes it hard to prioritize, so I’m going to keep it simple and stick to interventions that are most effective. Movement and sleep hygiene are simple steps with big returns in depression. For sleep, I go into detail: Where are the lights and noises coming from at night? For movement—I prefer that term to exercise—we might start with a short walk outside. If they are in bed all day, this one is non-negotiable. Connections are also very powerful in depression. Even in depression, patients will light up when talking about a fun social interaction or a date.

TCPR: What are common challenges in this work?
Dr. Ramsey: One is asking people to attend to their mental health before it’s a problem. I define “mental fitness” as the knowledge, patterns, habits, and skills that culminate in a more enjoyable, more mentally sound life. We start with knowledge. If people don’t know that sugary, fast, and processed foods are harmful to mental health, they aren’t going to change. From there we work on patterns, habits, and skills.

TCPR: How are patterns different from habits?
Dr. Ramsey: Patterns are what we observe in our lives—the cause and effect—as opposed to habits, which are things that we’re stuck in the pattern of doing. Identifying patterns also means seeing our role in these patterns. You might notice that your mood is worse after working the night shift, or that you keep getting involved with needy people and after a few months the relationship ends. It’s part of self-awareness.

TCPR: How do you keep self-awareness from turning into depressive rumination? 
Dr. Ramsey: Rumination is a kind of avoidance: stewing instead of making decisions and taking action in the real world. It helps for patients to be more aware of that pattern so they can see what they are avoiding. I want them to go into it—to get it out on the page and read it back to me. This is easier with telehealth, as the journal is usually nearby. Recording it helps them get perspective on the pattern and get out of the weeds.

TCPR: Final words?
Dr. Ramsey: The game has changed. The biggest threat to health today is mental health. We approach mental health reactively—paying attention to it only when things get bad. I’m calling for a mental fitness revolution, meaning that we should take more proactive steps. What happens when we start asking people about their mental fitness before they get psychiatrically ill?

TCPR: Thank you for your time, Dr. Ramsey.