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Nutrition Bulletin - 2022 - Jain - Association Between Vegetarian and Vegan Diets and Depression A Systematic Review

vegetarian and vegan diets and depression A systematic review

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Nutrition Bulletin - 2022 - Jain - Association Between Vegetarian and Vegan Diets and Depression A Systematic Review

vegetarian and vegan diets and depression A systematic review

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Victoria Hristova

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Received: 22 September 2021

| Revised: 4 January 2022

| Accepted: 4 January 2022

DOI: 10.1111/nbu.12540

REVIEW

Association between vegetarian and vegan diets and

depression: A systematic review

Rishika Jain1 | Phureephat Larsuphrom1 | Alexia Degremont1 |

Gladys Oluyemisi Latunde-Dada1 | Elena Philippou1,2

1
Department of Nutrition and Dietetics, Abstract
School of Life Course and Population
Sciences, King's College London, London, Recent evidence suggests that vegetarian and vegan diets may increase the risk
UK
2
and symptoms of depression, a mental health condition affecting 350 million peo-
Department of Life and Health Sciences,
University of Nicosia, Nicosia, Cyprus ple globally. We aimed to systematically review the literature on the associations
Correspondence
between vegetarian and/or vegan diets and the risk or symptoms of depression
Elena Philippou, 46 Makedonitissas using evidence from both observational and intervention studies. We followed
Avenue, 1700 Nicosia, Cyprus.
Email: [email protected] the Preferred Reporting Items for Systematic Reviews and Meta- Analyses
(PRISMA) guidelines, with pre-specification of all methods. A systematic search
Funding information
No external funding was received. for relevant papers was performed on Medline and Embase, Web of Science and
the Cochrane Library for cohort, case-control, cross-sectional studies or ran-
domised controlled trials examining associations between a vegetarian or vegan
diet and depression in adults. Three independent reviewers extracted data and
assessed risk of bias using the National Heart, Lung, and Blood Institute of the
National Institutes of Health for Quality Assessment of Observational Cohort and
Cross-Sectional Studies and Controlled Studies. Evidence was tabulated ac-
cording to the type of diet analysed as vegetarian, vegan or both and narratively
synthesised. A total of 23 studies (18 cross-sectional, three prospective cohort
and two randomised controlled trials) with 25 study outcomes were eligible for
inclusion in this review. Conflicting evidence was found on the association be-
tween vegetarian or vegan diets and depression. Eleven (44%) of the outcomes
indicated that vegetarian and vegan diets were associated with higher rates of
depression, while seven (28%) outcomes revealed beneficial effects of the diets
on depression. Seven (28%) outcomes found no association between vegetarian
and vegan diets and depression, although two of these studies found a higher
risk of depression in some groups. The quality of evidence was rated as good for
four of the studies with the remaining 19 studies rated as fair. The evidence on
the effect of vegetarian and vegan diets on depression is contradictory, possibly
due to the heterogeneity of the studies analysed. Further research, including
longitudinal and intervention studies, is required to resolve this observation.

Registry and registry number: PROSPERO, ID: CRD42019145817

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation

Nutrition Bulletin. 2022;47:27–49. wileyonlinelibrary.com/journal/nbu | 27

KEYWORDS
adults, depression, systematic review, vegan diet, vegetarian diet

I N TROD UC T I O N (Mensink et al., 2016) have been reported to be veg-

etarians. In the UK, 2% of adults and children (over
The burden of mental health disorders continues to 1.2 million individuals) are vegetarians (British Nutrition
grow, with significant impacts on health, society and Foundation, 2021). A vegetarian diet is a plant-based
economy globally (WHO, 2020). Depression in partic- diet based on foods derived from plants, including
ular is the fourth leading cause of disease burden in vegetables, wholegrains, legumes, nuts, seeds and
the world, reportedly affecting 4.7% of people, and it fruits, with some non-meat animal products (i.e. dairy
was predicted to become the second most prevalent foods, eggs or honey). Vegetarians can be classified as
disorder (after ischaemic heart disease) by the year ‘lacto-ovo-vegetarians’, who eat dairy foods and eggs
2020 (Prohan et al., 2014; WHO, 2020). It results from but not meat, poultry or seafood, ‘ovo-vegetarians’, who
a complex interaction of social, psychological and include eggs but avoid all other animal foods, includ-
biological factors, and is often associated with low ing dairy and ‘lacto-vegetarians’ who eat dairy foods
mood, low energy and loss of interest and enjoyment. but exclude eggs, meat, poultry and seafood. Vegans
Individuals often also suffer from anxiety, disturbed do not eat any animal products at all, including honey,
sleep and appetite, as well as feelings of guilt, low dairy and eggs and avoid any animal-derived ingredi-
self-worth, poor concentration and even medically ents in ready-made products (Alcorta et al., 2021).
unexplained symptoms (WHO, 2020). It is therefore Consumption of a vegetarian and/or vegan diet
critical to understand and study potential preventative might be associated with an increased risk of depres-
strategies to mitigate the adverse consequences of sion, since vegan diets are lacking in vitamin B12, and
depression. vegetarian and vegan diets may be low in long-chain
Notably, the contribution of modifiable lifestyle be- omega-3 polyunsaturated fats (PUFAs); nutrients which
haviours, such as physical inactivity and smoking, to are both important for brain function (Clarys et al.,
the development of mental health disorders (Jacka 2014). At the same time, however, a vegetarian and/or
et al., 2012), and the association between diet and vegan diet could also reduce the risk of depression, as
depression have received increased interest in recent they have a higher fruit and vegetable content than om-
years (Quirk et al., 2013). A number of systematic re- nivorous diets (Orlich et al., 2014). These foods are rich
views and meta-analyses on the association between in antioxidants, including vitamin C, vitamin E and beta-
mental health and dietary patterns, particularly the carotene, and may be able to counteract the inflamma-
Mediterranean diet, have been published (Beezhold tion in the brain associated with depression (Dantzer
& Johnston, 2012; Lassale et al., 2019; Molendijk et al., 2008; Kaur & Kapoor, 2001; Pandey & Rizvi,
et al., 2018; Rahe et al., 2014; Wolniczak et al., 2017). 2009). Furthermore, these diets are also associated
Some studies have also reported that fruit and vege- with an increased consumption of omega-6 PUFA, di-
table consumption is beneficial for reducing depres- etary fibre and phytoestrogens (Tordjman et al., 2016).
sion risk (Akbaraly et al., 2013; Khalid et al., 2016; Vegetarian diets are also associated with beneficial ef-
Konttinen et al., 2010; McMartin et al., 2012), while fects on metabolic disease including blood lipid profile
other studies found non-significant or even inverse and bodyweight and a reduced risk of adverse health
associations (Chi et al., 2016; Hintikka et al., 2005; outcomes, including diabetes, ischaemic heart disease
Kim et al., 2015; Mihrshahi et al., 2015; Tsai et al., and cancer risk (Oussalah et al., 2020).
2012). One caveat of these studies is that they only The interest in studying associations between veg-
focused on one component of diets; single nutrients etarian diets and mental health including depression
such as vitamin C and beta-carotene (Khalid et al., is evident in that three systematic reviews including
2016), or only fruits or vegetables. Studies focussing two meta-analyses have been recently published. A
on the association of depression with individual food meta-analysis on vegetarian diets and mental health
choices, nutrients and antioxidants have produced identified only 13 eligible studies and concluded that
inconsistent results, possibly because humans con- vegan or vegetarian diets were associated with a
sume diets and not individual foods or nutrients (Lai higher risk of depression (odds ratio: 2.142; 95% CI:
et al., 2014). 1.105–4.148) and lower anxiety scores (mean differ-
Recently, there has been much interest in the study ence: −0.847; 95% CI, −1.677–[−0.018]) in the whole
of the association between vegetarianism and depres- sample (Iguacel et al., 2021). In general, higher-
sion particularly since this dietary pattern has become quality studies and those in populations younger than
increasingly popular in the world. For example, approx- 26 years suggested a higher risk of all types of men-
imately 5% of Americans (Le & Sabate, 2014), 8% of tal disorders in vegetarians and vegans compared
Canadians (Ruby et al., 2013) and 4.3% of Germans with omnivores (Iguacel et al., 2021). The authors
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 29

reported that one possible explanation for these as- (Page et al., 2021), and was based on a predefined pro-
sociations is a reverse causal relationship between tocol (see Appendix S1) registered under PROSPERO
vegetarianism or veganism and mental health out- ID: CRD42019145817.
comes such that individuals who have psychosocial
disorders may be more inclined to follow a vegetarian
or vegan diet in order to improve their mental health. Search strategy for
Another systematic review and meta-analysis found identification of studies
no association between the consumption of a vege-
tarian diet and depression (pooled effect size using A computerised search strategy was implemented
10 studies: 1.02; 95% CI: 0.84–1.25, p = 0.817) (Askari using Medline via PubMed, EMBASE, Web of
et al., 2020). Both these meta-analyses included only Science and Cochrane Library from 1 January 2000
a small number of observational studies and further- to 31 March 2021. The search strategy combined the
more may provide misleading results since they in- following Medical Subject Heading (MeSH) and free-
cluded vegetarian and plant-based diets identified by text terms: “depression” OR “depressive disorder” OR
posteriori methods which may not meet the defini- “depressive disorder, major” OR “bipolar depression”
tion of a vegetarian diet (Fazelian et al., 2022). This AND “vegetarian” OR “vegetarian diet” OR “vegetari-
could be due to significant variations in the practice anism” OR “vegan” OR “vegan diet” OR “veganism”
of vegetarianism in the subjects. The most recently OR “whole food plant based” OR “plant based”. Three
published systematic review and meta-analysis on reviewers (RJ, PL and AD) independently selected
the association between vegetarian diets and de- the studies. Initially, obvious irrelevant studies were
pression included 16 observational studies (Fazelian excluded after screening titles and abstracts. The
et al., 2022). Nine of these studies were included in full texts of the remaining articles were then evalu-
a meta-analysis illustrating that adherence to a vege- ated carefully according to the eligibility criteria (as
tarian diet was associated with a 53% greater risk of shown below). Where required, any disagreement on
depression compared with a diet consumed by non- eligibility for inclusion was resolved by a fourth author
vegetarians (effect size: 1.53; 95% CI: 1.14, 2.07). (GOLD or EP).
The authors noted the paucity of evidence and high-
lighted the necessity of further studies on the subject
(Fazelian et al., 2022). Inclusion criteria
This systematic review, therefore aims to gather,
synthesise and update the literature on the association Articles were eligible for inclusion if they (i) were full-
between vegetarian diets and depression in individu- text articles; (ii) comprised cohort, case-control, cross-
als aged >18 years old, by including both observational sectional or randomised controlled trial (RCT) study
and intervention studies and extending the search up designs; (iii) examined associations between a vege-
to 31st March 2021. tarian dietary pattern, defined as the exclusion of meat,
fish and poultry from the diet; vegan dietary pattern, de-
fined as the exclusion of animal products entirely, and
M E T H OD S depression or depressive symptoms defined by either
self-report or diagnostic measurement tools in adults;
This systematic review follows the guidelines ad- and (iv) comprised study samples including individu-
dressed in the preferred reporting items for systematic als ≥18 years old. See PICOS criteria for inclusion and
reviews and meta-analyses (PRISMA) statement 2020 exclusion of studies (Table 1).

TA B L E 1 PICOS criteria for inclusion and exclusion of studies

Category Inclusion criteria Exclusion criteria

Population Individuals ≥18 years Individuals <18 years, animal studies

Intervention or Adherence to vegetarian or vegan diet Investigation of other dietary patterns or lifestyle
exposure factors rather than diet specifically
Comparator Omnivorous diet None
Outcome Depression or depressive symptoms Investigation of quality of life or other diseases/
outcomes rather than depression specifically
Study design Cohort study, case-control study, cross-sectional study, Systematic review, meta-analysis, intervention
randomised controlled trial study that is not a randomised controlled trial,
conference abstract, case report, survey, letter to
the editor
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
30 | JAIN et al.

Exclusion criteria and Cross- Sectional Studies following the guide-

lines provided (National Heart Lung & Blood Institute,
Studies were excluded if they (i) were published in lan- 2021). The NIH Quality Assessment Tool for Controlled
guages other than English; (ii) assessed animal mod- Studies was used to assess intervention studies.
els; (iii) investigated lifestyle patterns or other diets rich Both tools consist of 14 (different) questions as seen
in fruits and vegetables, but not vegetarian or vegan in Tables S1 and S2 with potential replies of yes/no.
diets specifically; (iv) examined individual dietary nu- These questions intend to evaluate the internal validity.
trients or components rather than diet as a whole; (v) For cohort and cross-sectional studies, this is the ability
investigated quality of life or disordered eating rather of the study to draw associative conclusions about the
than depression specifically; (vi) investigated mental effects of the exposures being studied on outcomes,
health disorders other than depression; and (vii) were and for controlled intervention studies, this is the abil-
systematic reviews, meta-analyses, intervention stud- ity of the study to make causal conclusions about the
ies that are not RCTs, conference abstracts, case re- effects of the intervention being tested (National Heart
ports, surveys or letters. As diagnostic tools used to Lung & Blood Institute, 2021).
assess depression in children and/or adolescents differ Some of the questions require some clarification to
from those used for adults, studies examining diet and understand how they were used for this review specif-
depression in populations younger than 18 years, preg- ically. In regard to the question about the timeframe,
nant women and post-natal women were also excluded this was judged to be sufficient as the majority of the
(Table 1). studies included individuals that had been following
a vegetarian diet since childhood, and the present
systematic review only included studies with individ-
Data extraction uals older than 18 years. Regarding the confounding
variables, these included age, sex, ethnicity, socio-
Three reviewers (RJ, PL and AD) independently ex- economic variables and other lifestyle behaviours
tracted information from each study on study design, such as exercise, sleep, weight and any other dis-
first author, publication year, country, number of partici- eases that an individual might have and were as-
pants, proportion of female participants, mean age/age sessed by questionnaires. The studies were critically
range of participants, population description, dietary appraised considering the risk of potential for selec-
assessment tool and focus, length of follow-up or inter- tion bias, information bias, measurement bias or con-
vention and depression assessment tool and its cut-off founding (the mixture of exposures that one cannot
score for depression diagnosis (where available). The tease out from each other). High risk of bias translates
study's main findings at the end of the follow-up pe- to a rating of poor quality, whereas a low risk of bias
riod (for observational studies) or intervention (for in- translates to a rating of good quality (National Heart
tervention studies) including the statistical associations Lung & Blood Institute, 2021). Study quality was rated
and significance, the confounders adjusted for and as poor if grading of ‘yes’ was only 0–4 out of 14 ques-
the authors’ summary of associations were extracted. tions, ‘fair’ if grading was 5–10 out of 14 questions and
Odds ratios or mean differences, respectively, for ob- ‘good’ if grading was 11–14 out of 14 questions. A ‘fair’
servational and intervention studies of diets or group study is susceptible to some bias but not sufficient to
interactions were also extracted. The direction of the invalidate the results.
effect of the outcome that favours either the vegetar-
ian or non-vegetarian diet, or showed no association,
was also recorded for the whole sample. The results of RESULT S
sub-group analyses were also recorded if these were
available. Results were synthesised based on the type Identification and selection of the included
of diet analysed (i.e. vegetarian or vegan or both) since manuscripts
dietary type might lead to different effects on the as-
sessed outcomes. A summary of the identification process can be found
in Figure 1. The combined search result gave a total of
3123 articles, of which 1490 were duplicates. Following
Quality assessment of included studies a screening of the titles and abstracts of the remaining
1633 articles, 1482 articles were excluded since they
Three reviewers (RJ, PL and AD) independently as- were irrelevant and 86 articles were excluded since
sessed the quality of included studies using the study the articles were reviews, abstracts, case reports and
quality assessment tool of the National Heart, Lung, animal studies. The final number of studies that met
and Blood Institute of the National Institutes of Health the inclusion criteria and were included in the review
(NIH) for Quality Assessment of Observational Cohort was 23.
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 31

F I G U R E 1 Flow diagram of the

selection process Literatures identified by search strategy Additional records identified through
PubMed (n = 914) other sources
Embase (n = 572) n=0
Web of Science (n = 1241)
Cochrane (n = 396)

Records after duplicates removed

n = 1633

Studies were excluded due to

irrelevant (n = 1482)
review (n = 37)
abstract (n = 29)
case reports (n = 15)
animal studies (n = 5)

Full-text articles assessed for eligibility

n = 65

42 studies were excluded, due to

intervention (not RCT) (n = 1)
irrelevant (n = 36)
surveys and letters (n = 2)
participants’ age < 18y (n = 3)

Studies included in this systematic review

(n = 23)

Description of the studies 2007; Norwood et al., 2019), four in Asia (Chai et al.,
2019; Hosseinzadeh et al., 2016; Kapoor et al., 2017;
Study characteristics Li et al., 2019), and one study combined Europe, Asia
and America (a grouping of populations from Germany,
As presented in Table 2, the majority of the included Russia, China and the US) (Lavallee et al., 2019).
studies (n = 20, 86%) were published after 2012.
Eighteen out of 23 (78%) were cross-sectional studies
(Baines et al., 2007; Beezhold et al., 2010; Chai et al., Assessment tools and heterogeneity
2019; Forestell & Nezlek, 2018; Hessler- Kaufmann in studies
et al., 2021; Hibbeln et al., 2018; Hosseinzadeh et al.,
2016; Jin et al., 2021; Kapoor et al., 2017; Lavallee et al., Heterogeneity was present in both the dietary as-
2019; Li et al., 2019; Matta et al., 2018; Meesters et al., sessment tools and the depression assessment tools.
2016; Michalak et al., 2012; Northstone et al., 2018; Assessment of habitual dietary intakes was done using
Norwood et al., 2019; Paslakis et al., 2020; Zamani (i) validated food frequency questionnaires (FFQs)
et al., 2020), three (13%) were cohort studies (Link (Beezhold et al., 2010; Hosseinzadeh et al., 2016; Jin
et al., 2008; Sánchez-Villegas et al., 2015; Shen et al., et al., 2021; Meesters et al., 2016; Sánchez- Villegas
2021), and the remaining two (9%) were RCTs (Agarwal et al., 2015; Shen et al., 2021; Zamani et al., 2020), (ii)
et al., 2015; Beezhold & Johnston, 2012). Six studies independently constructed or modified versions of a vali-
were conducted in Europe (Hibbeln et al., 2018; Matta dated FFQ (Hibbeln et al., 2018; Li et al., 2019; Matta
et al., 2018; Meesters et al., 2016; Michalak et al., et al., 2018; Northstone et al., 2018), (iii) General Eating
2012; Northstone et al., 2018; Sánchez-Villegas et al., Habits Scale (GEHS) (Forestell & Nezlek, 2018), (iv)
2015), another six in the US (Agarwal et al., 2015; other dietary recall methods (Northstone et al., 2018)
Beezhold & Johnston, 2012; Beezhold et al., 2010; and (v) self-reported questionnaires or a single dietary
Forestell & Nezlek, 2018; Jin et al., 2021; Link et al., habits question (Baines et al., 2007; Hessler-Kaufmann
2008), two were conducted in Australia (Baines et al., et al., 2021; Kapoor et al., 2017; Lavallee et al., 2019; Link
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
32 | JAIN et al.

TA B L E 2 Characteristics of eligible studies included in this review, grouped by study design, author and year of publication (presented
alphabetically within study design)

Length of
intervention
n subjects Age, years: mean or follow-up
Author, year Country (% female) (±SD) or range Population description period

RCT
Agarwal et al. (2015) USA 292 (79.8) ≥18 Individuals recruited from 10 corporate 18 weeks
sites of a major US insurance
company

Beezhold and Johnston USA 39 (82) n/a Adult men and women who reported 2 weeks
(2012) consuming meat and/ or poultry at
least once a day
Cohort
Link et al. (2008) USA 51 (75) 23– 86 English-speaking attendees at 12 weeks
Hippocrates Health Institute
Sánchez-Villegas et al. Spain 15 093 (58.6) N/A Former Spanish students of the 8.5 years
(2015) University of Navarra, registered
professionals from some Spanish
provinces and other university
graduates
Shen et al. (2021) Taiwan 3571 (74) 51.5 (±9.5) Buddhist Tzu Chi Foundation in Taiwan 9 years

Cross-sectional
Baines et al. (2007) Australia 9113 (100) 22–27 Australian women enrolled in the N/A
Australian Longitudinal Study on
Women's Health

Beezhold et al. (2010) USA 138 (55.8) OMN: 41.00 Volunteers from Seventh Day Adventist N/A
(± 1.40) (SDA) communities in the Phoenix,
VEG: 45.07 Arizona and Santa Barbara,
(± 1.42) California metropolitan areas
Chai et al. (2019) Malaysia 177 (100) 48.4 (± 12.3) Female vegetarians recruited from N/A
Buddhist and Hindu organisations in
Selangor, Malaysia
Forestell and Nezlek USA 6450 (57.5) 18.96 (±1.39) American university students N/A
(2018) 16–47

Hessler-Kaufmann et al. Germany 511 (63.4%) 43.4 (±18.1) Participants were recruited from two N/A
(2021) studies at the Institute for Nutritional
Medicine at the Technical University
of Munich
Hibbeln et al. (2018) UK 9668 (0) n/a Adult male partners of pregnant women N/A
in the (ALSPAC)
Hosseinzadeh et al. Iran 3846 (n/a) 36.4 (± 8.0) Iranian adults working in health centres N/A
(2016) 20– 55

Jin et al. (2021) USA 892 (47) 40–73 South Asians enrolled in the MASALA N/A
study, a community-based cohort
of South Asians from the San
Francisco Bay and the greater
Chicago areas
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 33

Dietary assessment Depression assessment

Cut-off Score for

Tool Type Tool depression diagnosis

Intervention Low-fat vegan diet SF-36 Scale of 0 to 100 –higher

score indicates better
health-related quality
of life
Intervention (i) Omnivore n/a 32
(ii) Fish
(iii) Vegetarian

Self-reported Question Adherence to raw vegan diet HADS ≥33.3

FFQ, validated, 136 items Pro-vegetarian Dietary Pattern (PDP) Self-reported question N/A

FFQ (i) Vegetarians Case diagnosis based on ICD-9 N/A

(ii) Non-vegetarians

Self-reported dietary (i) Do you exclude any of the following (i) SF-36 (i) <50
habits questionnaire, from your diet; (a) red meat (beef, (ii) Self-reported questionnaire (ii) n/a
3 items lamb, pork); (b) fish; (c) poultry?
(ii) ‘Vegetarian’ if they reported excluding
meat, poultry and fish from their diet
FFQ, validated, 152 items (i) Omnivores (i) DASS-42 (i) >18.4
(ii) Vegetarians (ii) POMS (ii) Males: >14.8, females:
>20.3

A 3-day dietary recall Dietary intake DASS-21 21-point scale (higher score
indicates more severe
depression)
GEHS (i) Vegan CESD ≥16
(ii) Lacto-vegetarian
(iii) Lacto-ovo-vegetarian
(iv) Pesco-vegetarian
(v) Semi-vegetarian
(vi) Occasional omnivore
(vii) Omnivore
Questionnaire (i) Vegetarians PHQ-9 n/a
(ii) Semivegan
(iii) vegan

FFQ, 17 items (i) Vegetarian EPDS ≥10

(ii) Non-vegetarian
FFQ, dish-based, (i) Fast food dietary pattern HADS ≥8
validated for Iranian (ii) Traditional dietary pattern
adults, 106 items (iii) Lacto-vegetarian dietary pattern
(iv) Western dietary pattern
FFQ, validated (i) Vegetarian CESD ≥16
(ii) Non-vegetarian
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
34 | JAIN et al.

TA B L E 2 (Continued)

Length of
intervention
n subjects Age, years: mean or follow-up
Author, year Country (% female) (±SD) or range Population description period

Kapoor et al. (2017) Pakistan 200 (25.5) 20– 40 General population of Mithi, Pakistan N/A

Lavallee et al. (2019) Germany 2007 (58.8) 51.95 (±17.36) Representative adults from Germany, N/A
Russia 3020 (53.2) 43.24 (±17.13) Russia and USA
USA 3038 (58.8) 55.12 (±17.50) University students from Germany and
Germany 1608 (63.9) 24.57 (±4.73) China
China 12 744 (62.1) 20.63 (±1.66)
Li et al. (2019) China 1051 (54.3) 60+ Elderly Chinese males from West N/A
Anhui, China

Matta et al. (2018) France 90 380 (53.2) 18–69 Volunteers living in 21 selected N/A
departments throughout
metropolitan France, in both rural
and urban settings
Meesters et al. (2016) Finland 4578 (55) Males: 53.3 (±13.7) Individuals from the population register N/A
Females: 51.2 (± of 5 large regions
13.9)
Michalak et al. (2012) Germany 4116 (54.3) 18–65 Respondents to the German National N/A
Health Interview and Examination
Survey (GHS)
Northstone et al. (2018) UK 10 780 (71.4) n/a Mothers and fathers taking part in the N/A
ALSPAC when their study child was
3–5 years old

Norwood et al. (2019) Australia 393 (83) 29.38 (±11.12) Adult community members and N/A
18–74 students from a large Australian
university

Paslakis et al. (2020) Germany 2499 (53.3%) 29.60 (±17.1) German residents N/A

Zamani et al. (2020) Iran 435 (100%) 31.37 (±7.52) The participants were selected from N/A
10 health care centres from the
Tehran University of Medical
Sciences (TUMS).
Note: Abbreviations: ALSPAC, Avon Longitudinal Study of Parents and Children; CESD, Centre for Epidemiological Studies Depression; DASS, Depression
Anxiety Stress Scale; EPDS, Edinburgh Postnatal Depression Scale; FFQ, Food Frequency Questionnaire; GDS, Geriatric Depression Scale; GEHS, General
Eating Habits Scale; HADS, Hospital Anxiety and Depression Scale; M-CIDI, Munich-Composite International Diagnostic Interview; MASALA, Mediators of
Atherosclerosis in South Asians Living in America; OMN, Omnivore; POMS, profile of mood states; RCT, randomised controlled trial; SAD, seasonal affective
disorder; SF-36, Short Form (36) Health Survey; SPAQ, Seasonal Pattern Assessment Questionnaire; VEG, vegetarian.

et al., 2008; Michalak et al., 2012; Norwood et al., 2019; studies using this tool assessed the male partners of the
Paslakis et al., 2020). Depression cases were also iden- pregnant women, and not the women themselves.
tified using varying tools, the most common being the
Depression Anxiety Stress Scale (DASS) and the Centre
for Epidemiological Studies Depression (CESD) scale. Study findings
Some other tools included the Hospital Anxiety and
Depression Scale (HADS) (Hosseinzadeh et al., 2016; Results of the 23 reviewed studies that assessed
Link et al., 2008), the Short Form Health Survey (SF-36) 25 study outcomes are presented in Tables 3–5. The
(Agarwal et al., 2015; Baines et al., 2007), the Hamilton extra two outcomes resulted from two studies that re-
Rating Scale for Depression (Kapoor et al., 2017) and the ported results for vegetarians and vegans separately
Edinburgh Postnatal Depression Scale (EPDS) (Hibbeln (Matta et al., 2018; Norwood et al., 2019). Studies
et al., 2018; Northstone et al., 2018). Note that the two were grouped separately into studies assessing only
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 35

Dietary assessment Depression assessment

Cut-off Score for

Tool Type Tool depression diagnosis

Questionnaire (i) Vegetarian Hamilton Rating Scale for n/a

(ii) Omnivore Depression (severity)
Self-reported Limitation of intake of meat/ meat DASS-21 21-point scale (higher score
Questionnaire products indicates more severe
depression)

FFQ (i) Meat-based diet GDS ≥11: minimal –mild

(ii) Balanced diet depression
(iii) Vegetable-based diet ≥21: moderate –severe
depression
FFQ, 24 items (i) Omnivores CESD ≥19
(ii) Pesco-vegetarian
(iii) Lacto-ovo-vegetarian
(iv) Vegan
FFQ, validated (i) Vegetarian SPAQ n/a
(ii) No special diet

Questionnaire (i) Completely vegetarian M- CIDI n/a

(ii) Predominantly vegetarian
(iii) Non-vegetarian
FFQ (i) Health conscious EPDS ≥12
(ii) Processed
(iii) Confectionary
(iv) Vegetarian
Questionnaire (i) Vegetarian DASS-21 21-point scale –higher
(ii) Vegan score indicates more
(iii) Paleo severe depression
(iv) Gluten-free
(v) Weight loss diet
(vi) Unrestricted diet
(vii) Another specific restricted diet
Self-reported dietary Vegetarian diets PHQ-4 ≥6
pattern
FFQ (i) overall plant-based diet (IPDI) DASS-21 n/a
(ii) healthful plant-based diet (hPDI)
(iii) unhealthful plant-based diet (uPDI)

vegetarian diets (19 studies, Table 3), only vegan diets Four cross-sectional studies (Beezhold et al., 2010;
(2 studies, Table 4), or vegetarian and vegan diets com- Hosseinzadeh et al., 2016; Jin et al., 2021; Zamani
bined (2 studies, Table 5). et al., 2020) reported vegetarian adults to have
lower rates of depression when compared to non-
vegetarians and two cohort studies found vegetarian
Evidence assessment adults to have a lower risk of developing depression
(Sánchez-Villegas et al., 2015; Shen et al., 2021). In
Vegetarian diet and the risk/ contrast, nine cross-sectional studies found that ad-
likelihood of depression herence to vegetarian diets was associated with an
increased risk of depression (Baines et al., 2007;
Twenty-
one of the 25 outcomes in this review as- Forestell & Nezlek, 2018; Hibbeln et al., 2018; Kapoor
sessed the effect of vegetarian diets on depression. et al., 2017; Li et al., 2019; Matta et al., 2018; Meesters
TA B L E 3 Summary of associations between a vegetarian diet and depression, presented by author and year of publication
36

Country, Adjusted for Summary of Direction Quality

Author, year sample size confounders Results p for trend* associations of effecta assessmentb

RCT
Beezhold and Johnston USA, n = 39 Age, sex, BMI, DASS-D baseline –week 2: OMN 0.984 No significant changes – Fair (7/14)
(2012) educational level, 1(2) –1(2) vs. VEG 1(4) –1(2) 0.448 in depression or
ethnicity, total POMS-D baseline –week 2: OMN anxiety. Mood
physical activity 3(5) –3(4) vs. VEG 3(10) –2(2) scores were
level, fatty acid unchanged for
intakes OMN or FISH
participants
but stress and
confusion improved
significantly for
VEG participants
after two weeks.
Cohort
Sánchez-Villegas et al. Spain, n = 15 Age, sex, BMI, Adherence: HR (95% CI) <0.001 Results suggest that 1 Good (12/14)
(2015) 093 smoking, Q1: 1 (reference) moderate or high
physical activity, Q2: 0.88 (0.74–1.04) adherence to diet
use of vitamin Q3: 0.52 (0.43–0.64) quality scores such
supplements, total Q4: 0.68 (0.57–0.82) as the PDP could
energy intake, Q5: 0.74 (0.61–0.89) be effective for
presence of the reduction in
disease at baseline depression risk
Shen et al. (2021) Taiwan, n = Age, sex, educational Incidence of depressive disorders Not provided Vegetarians had 1 Fair (8/14)
3571 level, marital status, in vegetarians was 2.37 vs 3.21 a lower risk
exercise habits, per 10 000 person-years in of developing
tobacco and alcohol non-vegetarians subsequent
consumption, (aHR): 0.70 (95% CI:0.52–0.93) depressive
and physical disorders
comorbidities compared with
non-vegetarians
Cross-sectional
Baines et al. (2007) Australia, n = Area (due to over- Depression diagnosis: VEG 20.2% <0.001 Depression in semi- 0 Fair (10/14)
9113 sampling of women vs. non-VEG 13.4% <0.001 VEG and VEG
from rural and Depression symptoms: VEG 29.3% is 21%–22% vs
remote areas) vs. non-VEG 19.5% non-VEG is 15%
-poorer mental
health in VEG
JAIN et al.

Country, Adjusted for Summary of Direction Quality

Author, year sample size confounders Results p for trend* associations of effecta assessmentb

Beezhold et al. (2010) USA, n =138 Age, sex, BMI, diet DASS-D: OMN 4.81 (±0.69) vs. VEG <0.001 Mean total DASS and 1 Good (12/14)
group 1.67 (±0.28) <0.001 POMS scores
POMS: OMN 8.99 (±0.80) vs. VEG significantly lower
4.36 (±4.10) in VEG than OMN
POMS scores higher in
females than males
POMS scores higher in
OMN females than
VEG females
VEGETARIAN DIETS AND DEPRESSION

Chai et al. (2019) Malaysia, n = Age, marital status, Depression: OR (95% CI) 0.934 Prevalence of – Fair (9/14)
177 percentage of Normal: 1.00 0.552 depression in VEG
energy from protein Mild: 1.04 (0.38–2.87) is 16.4%
Moderate/severe: 1.57 (0.36–6.85)
Forestell and Nezlek USA, n = 6450 Age, sex, ethnicity n/a (a) <0.001 (a) VEG and semi- 0 Fair (10/14)
(2018) (b) <0.047 VEG were more
(c) <0.001 depressed than
and OMN
(d) 0.003 (b) Women: semi-VEG
were significantly
more depressed
than OMN
Men: OMN were
significantly less
depressed than
(c) VEG and (d)
semi-VEG
Hessler-Kaufmann et al. Germany, n = Age, sex and BMI PHQ-9 of 5.22 (4.3) in semi- <0.05 Depressive –/0 Fair (10/14)
(2021) 511 vegetarian compared with 4.1 symptoms did not
(3.6) in omnivores. PHQ-9 of 4.5 differ between
(3.2) was observed in vegetarians vegetarians
and no significant differences and omnivores.
in PHQ-9 when compared to However, semi-
semi-vegetarians vegetarians with
strong orthorexic
tendencies show
more depressive
symptoms than
omnivores and
vegetarians.
|
37

(Continues)

Country, Adjusted for Summary of Direction Quality

Author, year sample size confounders Results p for trend* associations of effecta assessmentb

Hibbeln et al. (2018) UK, n = 9668 (i) Age, ethnic EPDS as continuous score, β (95% <0.0001 Self-identification as 0 Fair (9/14)
origin, housing CI) <0.0001 VEG is associated
tenure, number (i) 1.00 (0.56–1.43) with an increased
of children in (ii) 0.96 (0.53–1.40) risk of depressive
household, religion, EPDS score >10, OR (95% CI) symptoms
family history of (i) 1.71 (1.17–2.49)
depression, child (ii) 1.67 (1.14–2.44)
guidance,
(ii) As in (i), with
cigarette
and alcohol
consumption,
marital status,
employment status
Hosseinzadeh et al. (2016) Iran, n = 3846 (i) Age OR (95% CI): 0.80 (0.61–1.05) <0.05 3rd quintile of lacto- 1 Good (11/14)
(ii) Age, sex, marital OR (95% CI): 0.65 (0.48–0.87) vegetarians had
status, education, lower odds of
physical activity, depression
chronic diseases, No association
smoking, between VEG diet
antidepressant use, and depression in
energy intake men after adjusting
(iii) As in (ii), with BMI for sex
After adjustment for
age, women in 3rd
quintile of lacto-
vegetarians had
35% lower odds of
depression than
those in 1st quintile
Jin et al. (2021) USA, n = 892 Age, sex, study site, OR (95% CI): 0.57 (0.35, 0.92) (a) 0.049 (a) Prevalence of 1 Fair (9/14)
education, smoking, 0.023 depression was
BMI, acculturation, higher among non-
intentional exercise, VEG (14.4%) than
alcohol and VEG (9.9%)
energy intake, VEG had 43% lower
antidepressant odds of depression
medication use than non-VEG in
adjusted model
Kapoor et al. (2017) Pakistan, n = Sex Depression: VEG 31% vs. OMN 12% <0.002 Neurological problems 0 Fair (9/14)
200 like depression are
more common in
vegetarians
JAIN et al.

Country, Adjusted for Summary of Direction Quality

Author, year sample size confounders Results p for trend* associations of effecta assessmentb

Lavallee et al. (2019) Germany, n = Age, sex, marital n/a (a) 0.048 (a) US: VEG more –/0 Good (11/14)
2007 adults status, urbanicity, (b) 0.087 depressed than
Russia, n = socio-economics (c) 0.045 non-VEG
3020 adults (b) In Chinese
USA, n = 3038 students, VEG diet
adults is related to higher
Germany, n levels of depression
= 1608 (c) Predictive effect
University of VEG diet on
VEGETARIAN DIETS AND DEPRESSION

students depression only in

China, n = Chinese student
12744 sample
University In sum: VEG diet
students does not a reliable
predictor of mental
health in German,
US, or Russian
representative or
German student
samples, but
predicts slight
increases in
depression over
time in Chinese
students
Li et al. (2019) China, n = 1051 Sex, education, Depression score: 8.78 (±6.894) 0.001 VEG diets associated 0 Fair (10/14)
occupation, Depression rate: 32.9% 0.003 with increased risk
marital status, Ordinal variables: OR (95% CI) <0.01 of depression in
residence, living Logistic regression: 1.48 (1.11–1.97) <0.01 elderly men
alone, religion, Linear regression: 0.93 (0.36–1.50) <0.05
annual family Dummy variables: OR (95% CI) <0.001
income, self-rated Logistic regression: 2.97 (1.27–6.94) <0.01
health, alcohol Linear regression: 2.32 (1.00–3.63)
consumption Ordinal regression: 3.37 (1.39–5.26)
|
39

(Continues)

Country, Adjusted for Summary of Direction Quality

Author, year sample size confounders Results p for trend* associations of effecta assessmentb

Meesters et al. (2016) Finland, n = Finland Vegetarians among SAD sufferers <0.001 SAD is a significant 0 Fair (9/14)
4578 Sex 3.8% vs. vegetarians in control 0.006 predictor of
0.8% <0.001 vegetarianism in
Logistic regression: OR (95% CI) 0.007 total sample and
Total sample 3.9 (1.84–8.45) women (not in men)
Women 3.2 (1.39–7.23) Vegetarianism is a
12.9% of self-reported vegetarians significant predictor
suffer from SAD of SAD in total
Logistic regression: OR (95% CI) sample and women
Total sample 3.9 (1.81–8.36) (not in men)
Women 3.1 (1.37–7.16)
Michalak et al. (2012) Germany, n = Age, sex, educational Prevalence completely/ n/a 12-month and lifetime 0 Fair (10/14)
4116 level, community predominantly vs. matched non- prevalence rates
size, marital status VEG: OR (95% CI) of depressive
1-month: 1.44 (0.67–3.07) disorders were
12-month: 1.75 (1.03–2.99) 15% higher in
Lifetime: 1.48 (0.98–2.26) completely VEG
Prevalence completely vs. matched (35.2%) vs.
non-vegetarians: OR (95% CI) non-VEG (19.1%)
1-month: 1.53 (0.48–4.95) (20.7% in matched
12-month: 2.75 (1.30–5.82) non-vegetarian
Lifetime: 2.09 (1.10–3.95) sample)
Northstone et al. (2018) UK, n =10780 Age, education, Women: OR (95% CI) 0.134 Unlikely that overall – Fair (9/14)
ethnicity, housing Whole cohort: 0.94 (0.87–1.02) 0.814 dietary patterns
tenure, marital Restricted sample: 1.01 (0.92–1.11) 0.315 contribute to
status, health Men: OR (95% CI) 0.303 development
status, overcrowded Whole cohort: 0.86 (0.64–1.16) of depressive
accommodation, Restricted sample: 0.85 (0.62–1.16) symptoms (effects
anxiety score seen, but all
associations lost
after adjusting for
confounders)
Paslakis et al. (2020) Germany, Gender and age PHQ-4 of 2.02 (2.31) in vegetarian 0.21 There were no – Fair (8/14)
n = 2499 compared with 1.54 (2.11) in significant
omnivores differences
in depressive
symptoms between
vegetarians and
omnivores
JAIN et al.

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14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 41

‘1’: favours vegetarian diet, that is showing a beneficial association between vegetarian diet and depression, ‘0’: favours omnivorous diet or other diets, that is showing an adverse association between vegetarian diet
et al., 2016; Michalak et al., 2012; Norwood et al.,

Abbreviations: BMI, body mass index; CI, confidence interval; DASS-D, Depression Anxiety Stress Scale for Depression; EPDS, Edinburgh Postnatal Depression Scale; HR, hazard ratio; OMN, omnivore; OR, odds
assessmentb

Risk of bias within studies was assessed using the study quality assessment tool of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) for Quality Assessment of Observational
2019). Five cross-sectional studies assessing the re-

Fair (10/14)
lationship between a vegetarian diet and depression
Quality

found no association between the two (Chai et al.,

2019; Hessler-Kaufmann et al., 2021; Lavallee et al.,
2019; Northstone et al., 2018; Paslakis et al., 2020).
The Lavallee et al. (2019) study, however, found no
Direction
of effecta

association between vegetarianism and depression in

ratio; PDP, pro-vegetarian dietary Pattern; POMS-D, profile of mood states for depression; Q, quintile; RCT, randomised controlled trial; SAD, seasonal affective disorder; VEG, vegetarian.
the US, German and Russian representative samples
1

or in German student samples but found that vege-

tarianism was related to slight increases over time in
diet and healthful

anxiety and depression in Chinese students (Lavallee

Overall plant-based

plant-based diet

associated with
were inversely

et al., 2019). Hessler-Kaufmann et al. (2021) also

depression
associations

showed that semi-vegetarians with strong orthorexic

Summary of

tendencies show more depressive symptoms than

omnivores and vegetarians. One pilot RCT examin-
ing whether an intervention with a vegetarian diet im-
proves depression scores did not find any differences
between omnivorous, fish and vegetarian diets after
p for trend*

two weeks (Beezhold & Johnston, 2012).

0.003
0.001

Vegan diet and the risk/

*p for trend values are in line with the results to which they are relevant, unless otherwise indicated (significant values are in bold).

likelihood of depression
hPDI: 0.44; 95% CI 0.25–0.76

Four of the 25 outcomes in this review assessed the

PDI: 0.41; 95% CI 0.23–0.71

effect of vegan diets on depression. One RCT found

vegan diets to improve depression indicators as-
sessed using the Short Form-3 6 questionnaire after
18 weeks (Agarwal et al., 2015). One cohort study
found vegan diets to be beneficial for reducing de-
pression, but the findings were non-significant (Link
Results

et al., 2008). In contrast, two cross-sectional studies

found vegan diets to be associated with depression
(Matta et al., 2018; Norwood et al., 2019), with one
of these showing that vegan diets are associated
Cohort and Cross-Sectional Studies (National Heart Lung & Blood Institute, 2021).
status and marital
physical activity,
Energy intake, age,

socio-economic

with depression even more than vegetarian diets

(Norwood et al., 2019).
confounders
Adjusted for

and depression, ‘–’: no effect between vegetarian diet and depression.

status

Quality assessment

Of the 23 studies, only four (17%) studies were rated

as ‘good’ (Beezhold et al., 2010; Hosseinzadeh et al.,
sample size

Iran, n = 435

2016; Lavallee et al., 2019 and Sánchez- Villegas

Country,

et al., 2015), with the remaining 19 (83%) stud-

ies rated ‘fair’ (Agarwal et al., 2015; Baines et al.,
2007; Beezhold & Johnston, 2012; Chai et al., 2019;
Forestell & Nezlek, 2018; Hessler-Kaufmann et al.,
2021; Hibbeln et al., 2018; Jin et al., 2021; Kapoor
(Continued)

et al., 2017; Li et al., 2019; Link et al., 2008; Matta

Zamani et al. (2020)

et al., 2018; Meesters et al., 2016; Michalak et al.,

2012; Northstone et al., 2018; Norwood et al., 2019;
Author, year

Paslakis et al., 2020; Shen et al., 2021; Zamani et al.,

TA B L E 3

2020). A meta-analysis was not conducted due to

the heterogeneity of the studies in terms of assess-
ments and outcomes.
a

b
42
|

TA B L E 4 Summary of associations between a vegan diet and depression, presented by author and year of publication

Country, Adjusted for Direction of Quality

Author, year sample size confounders Results p for trend* Summary of associations effecta assessmentb

RCT
Agarwal et al. USA, n = 292 Sex, cluster and Within-group difference intervention: <0.001 Current findings suggest that 1 Fair (8/14)
(2015) psychiatric −7.18 0.76 intervention using a low-fat
medications Control: 0.49 0.004 V diet improves indicators
Between-group difference in change (a) 0.02 of depression
score, adjusted: OR (95% CI) (a) Intention-to-treat analysis
6.36 (2.06–10.70) saw improvements in
depression in intervention
group
Cohort
Link et al. USA, n = 51 Sex, education, HADS score (abnormal ≥33.3) 0.28 Mean depression score – Fair (9/14)
(2008) socio-economic Baseline: 22.7 decreased (−8.8%)
status, history of 12 weeks: 20.7 non-significantly
cancer Depression score improved
more in group who
started raw V diet during
the study than controls
(non-significant)
Abbreviations: CI, confidence interval; HADS, Hospital Anxiety and Depression Scale; OR, odds ratio; RCT, randomised controlled trial; V, vegan.
a
‘1’: favours vegan diet, that is showing a beneficial association between vegan diet and depression, ‘0’: favours omnivorous diet or other diets, that is showing an adverse association between vegan diet and
depression, ‘–’: no effect between vegan diet and depression.
b
Risk of bias within studies was assessed using the study quality assessment tool of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) for Quality Assessment of Observational
Cohort and Cross-Sectional Studies (National Heart Lung & Blood Institute, 2021).
*p for trend values are in line with the results to which they are relevant, unless otherwise indicated (significant values are in bold).
JAIN et al.

Country, Direction of Quality

Author, year sample size Adjusted for confounders Results p for trend* Summary of associations effecta assessmentb

Cross-sectional
Matta et al. France, n = 90 (i) Age, sex, education, (a) OR (95% CI): 1.36 (1.09–1.70) Crude: <0.05 (a) Association between 0 Fair (9/14)
(2018) 380 household income (b) OR (95% CI): 2.84 (2.27–3.57) Adjusted: depressive symptoms
VEGETARIAN DIETS AND DEPRESSION

(ii) As in (i), with frequency (c) VEG/V diet to stay healthy: OR <0.0001 and diet type was
of fruits, vegetables, (95% CI) (b) <0.0001 significant in crude
legumes and grains YES: 1.40 (1.07–1.82) associations (remained
consumption NO: 3.00 (2.36–3.80) significant after adjusting
(iii) as in (ii), with smoking, for confounders)
alcohol consumption and (b) Significant association
physical activity between VEG diet low in
legumes and depression
(c) VEG and V diets
were associated with
depressive symptoms
to a lower extent in
participants reporting
eating as being merely a
mean to stay healthy
Norwood et al. Australia, n = Age, sex, ethnicity, BMI, Mean depression score 0.042 Significant difference 0 Fair (10/14)
(2019) 393 time on diet, diet-related VEG: 6.38 between diet groups in
medical condition V: 8.66 depression
Mean depression scores of
V and VEG diets higher
than unrestricted diet
–V more depressed
than VEG (but both have
lower depression score
than weight loss diet)
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio; V, vegan; VEG, vegetarian.
a
‘1’: favours vegetarian/vegan diet, that is showing a beneficial association between vegetarian/vegan diet and depression, ‘0’: favours omnivorous diet or other diets, that is showing an adverse association between
vegetarian/vegan diet and depression, ‘–’: no effect between vegetarian/vegan diet and depression.
b
Risk of bias within studies was assessed using the study quality assessment tool of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) for Quality Assessment of Observational
Cohort and Cross-Sectional Studies (National Heart Lung & Blood Institute, 2021).
*p for trend values are in line with the results to which they are relevant, unless otherwise indicated (significant values are in bold).
|
43

D I SCUS S I O N included in the meta-analysis. 10/13 of the studies were

rated as high quality and 3/13 as low quality. Therefore,
This systematic review identified 23 studies with although Fazelian et al. (2022) concluded that vegetar-
25 study outcomes that investigated the association ian diets increase risk of depression, the evidence is
between vegetarian or vegan diets and depression and weakened by the mixed body of evidence that is re-
revealed conflicting evidence. As such, 11/25 (44%) of ported in the current review.
the included outcomes suggested that vegetarian or A number of possible reasons may be suggested
vegan diets are associated with higher rates of depres- to explain the inconsistency of findings of the studies
sion, while 7/25 (28%) of the included outcomes sug- reviewed. The current study included studies from dif-
gested that these dietary patterns are associated with ferent countries which may, due to cultural differences
lower risk and symptoms of depression and 7/25(28%) or agricultural practices, vary considerably in the com-
found no association between vegetarian diets and de- position of typical vegetarian or vegan diets. The du-
pression, although two of these studies found a higher ration of observation or intervention, the participants’
risk of depression in some groups. It is of note, how- characteristics (e.g. age, BMI and health status), the
ever, that all nine of the studies associating vegetarian reason for adopting a vegetarian diet and the overall
or vegan diets with a higher risk of depression and four quality of the studies might also result in different find-
of the studies associating vegetarian or vegan diets ings. Additionally, adjustment for potential confounding
with a lower risk of depression (Agarwal et al., 2015; Jin factors which may have affected both exposure and
et al., 2021; Shen et al., 2021; Zamani et al., 2020) were outcome measures such as BMI, physical activity, edu-
scored as ‘fair’ in the quality assessment. These stud- cation, marital status, smoking, mental status and use
ies, as well as another study (Beezhold & Johnston, of vitamin supplements varied in the studies. There
2012) that found no associations, have methodological also remains the possibility that there is truly no asso-
limitations as discussed below. On the contrary, of the ciation between vegetarian or vegan diets and depres-
studies rated as ‘good’ in terms of quality, one study sion, and any findings are merely due to chance.
(Lavallee et al., 2019) associated vegetarian/vegan Several factors might underlie the findings of an
diets with either no risk or a higher risk of depression increased risk of depression among vegetarians and
(depending on the population) and three studies as- vegans seen in some studies. For example, individuals
sociated these diets with a lower risk of depression following vegetarian and vegan diets may be deficient
(Beezhold et al., 2010; Hosseinzadeh et al., 2016; in certain nutrients compared with omnivorous diets
Sánchez-Villegas et al., 2015). Overall, this suggests (Clarys et al., 2014), as a result of, either a reduced
that although the balance of the evidence, albeit largely intake, or a low bioavailability for absorption such as
correlational, is tilted towards a positive association in the case of iron. Haem iron, found predominantly in
between vegetarian and vegan diets and depression, meat, poultry and fish, has a higher bioavailability than
there is a need for further good-quality evidence since non-haem iron, found in vegetables, cereals and lentils
three of the four high-quality studies show that vegetar- (Young et al., 2018). This means that individuals ad-
ian diets are associated with a lower risk of depression. hering to a vegetarian or vegan diet are more prone to
As mentioned in the Introduction, three previous sys- lower iron stores which may increase the risk of iron
tematic literature reviews (SLRs) and meta- analyses deficiency anaemia (Haider et al., 2018). Evidence from
have assessed the associations between vegetarian cross-sectional studies has indeed revealed a signifi-
diets and depression (Askari et al., 2020; Fazelian cant association between iron deficiency and depres-
et al., 2022; Iguacel et al., 2021). Two of these SLRs sion (Onder et al., 2005; Vulser et al., 2016). Another
were limited in that they included a smaller number of nutrient deficiency that might predispose vegetarians
observational studies as well as diets identified by pos- and vegans to depression more than omnivores is vi-
teriori methods (Askari et al., 2020; Iguacel et al., 2021). tamin B12 (Bjelland et al., 2003; Coppen & Bolander-
The most recently conducted SLR and meta-analysis Gouaille, 2005; Penninx et al., 2000; Tiemeier et al.,
(Fazelian et al., 2022) included fewer studies (n = 16) 2002). Vitamin B12 deficiency is linked to high plasma
than the current SLR which were only observational, homocysteine levels, which could increase the risk of
while the current SLR includes both observational and depression (Chung et al., 2017; Narayan et al., 2014).
intervention studies and extended the search date up High homocysteine concentrations can damage brain
to 31 March 2021. This might have affected the findings neurons and cerebral vasculature, thereby inducing
both due to the inclusion of more diverse and larger cell death. This alters the central brain neurotransmit-
samples and to the inclusion of the two small interven- ters by causing psychiatric disturbances and increasing
tion studies. In terms of quality assessment, the two re- the risk of depression (Coppen & Bolander-Gouaille,
views cannot be directly compared since the Fazelian 2005).
et al. SLR used the Newcastle Ottawa Scale (Wells Another nutrient that may be low in the diets of veg-
et al., 2014) for quality assessment which comprises etarians and vegans is long-chain omega-3 fatty acids
eight questions to assess the 13/16 studies that were (Saunders et al., 2013). This could increase the risk of
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VEGETARIAN DIETS AND DEPRESSION | 45

depression since several studies have reported that essence, vegetarian and vegan diets could theoretically
omega-3 fatty acid concentration in red blood cells is lower depressive symptoms by enhancing the concen-
lower in depressed individuals compared with controls tration of neurotransmitters in the brain and reducing
(Edwards et al., 1998; Lin & Su, 2007; Peet et al., 1998; inflammation (Haghighatdoost et al., 2017). In contrast,
Su et al., 2003). Reduced concentrations of omega-3 meat contains compounds such as the long-chain fatty
fatty acids in the brain can cause significant changes acid arachidonic acid (AA), which has neuroinflamma-
in brain function, including changes in neuron size, tory effects (Regulska et al., 2021).
learning and memory, auditory and olfactory responses It is of note that there is a wide variation, ranging from
to stimuli, and changes in nerve growth factor levels n = 51 to n = 90 380, in the number of participants in the
(Sinclair et al., 2007). The underlying mechanisms are studies analysed in the current review. The number of
still unclear, but it is hypothesised that they are twofold participants, however, does not seem to exert any spe-
(Grosso et al., 2014). First, omega-3 fatty acids play a cific effect on the study findings. Moreover, some of the
role in the metabolism, release, uptake, and receptor studies were conducted in specific population groups
function of serotoninergic and dopaminergic transmis- that adopt vegetarian diets due to ethical or religious
sion. Primarily, omega-3 fatty acids increase cerebro- reasons, for example Buddhists (Shen et al., 2021) and
spinal fluid 5-hydroxyindole-acetic acid (CSF 5-HIAA), where people are more likely to have grown up as vege-
the metabolite that increases serotonin concentration in tarian or vegan. Only one study (Chai et al., 2019) with a
the synaptic cleft, which in turn improves mood (Grosso population of 177 participants was conducted in a pop-
et al., 2014). Omega-3 fatty acids also increase dopa- ulation (Malaysia), where mainstream religions adopt
mine levels in the frontal cortex and increase binding to vegetarianism. This may be important since the rea-
dopamine receptors, resulting in a mood boost (Healy- sons or motivations for adopting vegetarianism might
Stoffel & Levant, 2018). Second, omega-3 fatty acids reflect mental health status (Rosenfeld, 2019). For ex-
have anti-inflammatory effects and could reduce pro- ample, associated behaviours such as the practice of
inflammatory cytokines, characteristic of depressed in- compassion towards animals, relaxation techniques
dividuals (Kopschina Feltes et al., 2017). such as meditation, and the adoption of vegetarian
In contrast to the above, other studies associated diets to conserve the environment could influence the
vegetarian and vegan diets with a lower risk of depres- mental health status of adherents. Education and/or af-
sion. The most apparent reason linking vegetarian diets fluence might lead to adoption of vegetarianism in later
to a possible lower risk of depression is that these diets life in some cultures due to increased knowledge on
have a higher fruit and vegetable content than omnivo- health benefits, while vegetarianism may be adopted
rous diets (Orlich et al., 2014). These foods are rich in by others due to dietary restraint or out of necessity as
antioxidants and may be able to counteract the inflam- it may be a less expensive choice. In addition, nutrient
mation in the brain associated with depression (Dantzer composition and quality of the diet consumed may also
et al., 2008; Kaur & Kapoor, 2001; Pandey & Rizvi, vary by age and socio-economic factors. It would there-
2009). Additionally, studies have found that depressed fore be instructive for further research to investigate the
individuals have elevated levels of monoamine oxidase impact of vegetarianism on mental health in a natural
(MAO), an enzyme that breaks down neurotransmitters setting such as India with high, traditional rates of veg-
involved in the regulation of mood (Meyer et al., 2006). etarianism from childhood.
High concentrations of MAO would result in decreased This review has a number of strengths and limita-
concentrations of these neurotransmitters, which can tions. With regards to limitations, a high level of het-
cause depression (Nutt, 2008). Fruits and vegetables erogeneity was observed in the tools used for diet and
also contain high concentrations of phytochemicals depression assessment, which may explain some of
(Prior & Cao, 2000) and quercetin, a phytochemical the inconsistencies observed. Similarly, the wide va-
found exclusively in plant foods, functions as a MAO riety of assessment tools for depression and the dif-
inhibitor at levels found in a healthy diet (Dixon Clarke ferent cut-offs used could have also complicated the
& Ramsay, 2011). It prevents the enzymatic catabolism outcomes. Two studies (Baines et al., 2007; Sánchez-
of serotonin, dopamine and norepinephrine by MAO, Villegas et al., 2015) assessed depression using self-
thereby improving mood. reported methods which could have resulted in the loss
Furthermore, vegetarian and vegan diets are typically of clinically significant information (Uher et al., 2012)
richer in carbohydrates (such as grains, beans, fruits and one study (Shen et al., 2021) that associated veg-
and vegetables) in comparison with other diets (e.g. etarian diets with lower risk of depression, ascertained
low-carbohydrate diets) (Wurtman & Wurtman, 1995), incident depression only indirectly through linkage to
which result in elevated insulin concentrations in the the National Health Institute Research Database. This
blood. This subsequently drives tryptophan across the may be problematic since people that seek help for
blood–brain barrier, which, via the 5-hydroxytryptophan depression might be characterised by certain person-
intermediate, is converted to serotonin, a neurotrans- ality or health characteristics, including diet and other
mitter that reduces depression (Richard et al., 2009). In lifestyle factors that are different to people not seeking
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46 | JAIN et al.

help or not reporting their symptoms. Additionally, one sample and in women individually, but not in men.
(Agarwal et al., 2015) of the two RCTs included in the The second study found no association between de-
review did not assess depression using a recognised pression and the likelihood of adhering to a vegetarian
mental health assessment tool. Physical and emotional diet (Lavallee et al., 2019). Thus, the reverse causation
wellbeing were assessed with the 36-Item Short Form hypothesis needs further exploration and longitudinal
Health Survey (SF-36) with the addition of two sub- studies would enable a better understanding of this
scales to isolate specific mental health measures of de- association.
pression and anxiety, thus raising questions on validity. A further limitation of this systematic review relates to
Although the remaining studies used formal diagnostic the quality assessment tool used which, although vali-
tools (which more accurately classify individuals as de- dated, may have not been sensitive enough to address
pressed), a total of 11 different tools were used. This some pertinent issues that are relevant here such as
too could have obscured significant associations as the type of intervention and control diet, the methods
each study has different cut-offs for depression diag- used to assess outcomes and the adequacy of covari-
nosis, and thus, they may all assess different aspects ates assessed. Furthermore, quality assessment might
to reach a final diagnosis. Additionally, only one study have resulted in some disparities in the rating of the
assessed diet quality in addition to diet type, something studies, as this was based on individual judgement.
that could introduce bias in the outcomes (Sánchez- Regarding the strengths of the review, it reviewed
Villegas et al., 2015). the largest number of studies to date on the association
The two RCTs included in this review have import- between vegetarian diets and depression. Moreover,
ant limitations in their methodology. The Beezhold and it is the only review that included both observational
Johnston (2012) study was only a 2-week pilot study and intervention studies. Furthermore, it focused on
and reported a significant difference in the assessment the whole diet rather than on specific nutrients or food
of confusion at baseline between the study groups. The groups. While it is important to delineate the associa-
(Argawal et al., 2015) study, a multicentre study, ran- tion of specific nutrients or single food items with de-
domised sites to either a low-fat, vegan diet or to no pression as in previous reports, the analysis of dietary
intervention. Only the intervention sites participated in patterns and depression performed in the current study
weekly group meetings which included instructions and presents a real-life situation. This is because the com-
group support which might contribute to positive mood plementation and the synergy of nutrients, bioactive
changes and potentially introduce bias. A further lim- ingredients or food variety offer credibility to vegetar-
itation is the heterogeneity in the participants included ian and vegan diets as wholesome. Another strength
in this review, who were from different geographical is the fact that the majority of studies included in this
areas, cultural and religious backgrounds, and of vary- systematic review adjusted for most of the known po-
ing ages, in addition to the large differences in sample tential confounders, such as age, sex, ethnicity, socio-
sizes between studies. There are also other potentially economic variables and other lifestyle behaviours.
confounding factors in the diet and depression associ-
ation that might not have been accounted for, including
the participants having any form of illness or partici- CO N CLUS I O N
pants taking supplements such as vitamin B12 or ome-
ga-3 fatty acids at the time of the study. To improve the This review systematically investigated the associa-
quality of the evidence, future studies should also take tion between vegetarian or vegan diets and depression
into account known risk factors for depression such as and revealed conflicting evidence. While some studies
gender, early adverse experience, genes, stress, cog- indicated that individuals on vegetarian diets had higher
nitive impairments and social support and assess nutri- rates of depression, other studies suggested that this
tional status or the healthiness of the dietary patterns. dietary pattern is beneficial for depression, its risk and
Additionally, it is of note that the majority of the stud- symptoms. Although the evidence is limited, three good-
ies included in this review were cross-sectional, which quality studies showed that vegetarian diets were associ-
are unable to determine causality. Although following a ated with a lower risk of depression; there were, however,
vegetarian diet might be associated with an increased more studies showing adverse effects. Since this is a
or reduced risk of depression, there is, however, the relatively new field of research, as evidenced by the small
possibility of reverse causation (i.e. depressed individ- number of studies available for inclusion in this review,
uals deciding to follow a vegetarian or vegan diet with the very limited evidence from RCTs and given the het-
the hope of improving their health). As such, two stud- erogeneity of the studies, further research is warranted to
ies in this review looked at depression as a predictor of determine whether a causal relationship exists. Higher-
diet. One of these found a significant association be- quality studies using consistent tools to measure diet and
tween depression and the increased likelihood of those depression will ensure that the findings are comparable
individuals adhering to a vegetarian diet (Meesters and delineate any relationship if it exists. Moreover, longi-
et al., 2016). This association was seen in the total tudinal studies are warranted to investigate the long-term
14673010, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nbu.12540 by CochraneBulgaria, Wiley Online Library on [10/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
VEGETARIAN DIETS AND DEPRESSION | 47

Bjelland, I., Tell, G.S., Vollset, S.E., Refsum, H. & Ueland, P.M. (2003)
effects of vegetarianism on mental health in countries Folate, vitamin B12, homocysteine, and the MTHFR 677C-
>T polymorphism in anxiety and depression: the Hordaland
such as India where the diet choice is a life course prac-
Homocysteine Study. Archives of General Psychiatry, 60,
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novel preventive and therapeutic strategies for individu- British Nutrition Foundation (2021) Healthy eating for vegetarians
als prone to or suffering from depression. and vegans. Available from: https://www.nutrition.org.uk/putti
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AC K N OW L E D G E M E N T S
Chai, Z.F., Gan, W.Y., Chin, Y.S., Ching, Y.K. & Appukutty, M. (2019)
RJ, EP and GOLD designed the research. RJ and Factors associated with anemia among female adult vegetarians
AD conducted the research. RJ, PL and AD analysed in Malaysia. Nutrition Research and Practice, 13, 23–31.
data. RJ and EP wrote the paper. EP, PL and GOLD Chi, S.H., Wang, J.Y. & Tsai, A.C. (2016) Combined association of
revised the paper. EP had primary responsibility for leisure-time physical activity and fruit and vegetable consump-
tion with depressive symptoms in older Taiwanese: Results of a
final content. All authors read and approved the final
national cohort study. Geriatrics and Gerontology International,
manuscript. 16, 244–251.
Chung, K.-H., Chiou, H.-Y. & Chen, Y.-H. (2017) Associations be-
CONFLICT OF INTEREST tween serum homocysteine levels and anxiety and depression
The authors declare no conflict of interest arising from among children and adolescents in Taiwan. Scientific Reports,
7, 8330.
the conclusions of this work.
Clarys, P., Deliens, T., Huybrechts, I., Deriemaeker, P., Vanaelst, B.,
De Keyzer, W. et al. (2014) Comparison of nutritional quality of
DATA AVA I L A B I L I T Y S TAT E M E N T the vegan, vegetarian, semi-vegetarian, pesco-vegetarian and
The data that support the findings of this study are omnivorous diet. Nutrients, 6(3), 1318–1332.
available from the corresponding author upon reason- Coppen, A. & Bolander-Gouaille, C. (2005) Treatment of depres-
sion: time to consider folic acid and vitamin B12. Journal of
able request.
Psychopharmacology, 19, 59–65.
Dantzer, R., O'Connor, J.C., Freund, G.G., Johnson, R.W. & Kelley,
ORCID K.W. (2008) From inflammation to sickness and depres-
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org/0000-0002-0607-6909 Reviews Neuroscience, 9, 46–56.
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