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While there is no easy solution at present, the increased academic emphasis on the emerging lifestyle medicine field should increase awareness and, with an evolving evidentiary base, be able to interface more profoundly with policy makers and clinical bodies. In respect to specific effects on mental health outcomes from sauna, there is overwhelming anecdotal evidence from traditional folklore (46), but minimal scientific or sociological evidence. While it is understood that this paper does not follow a strict reductive analysis of specific techniques for specified psychiatric disorders, it is intended to provide a paradigm to be able to expand a different way of thinking, particularly for the consideration of novel interventions that may work alongside conventional treatments to enhance mental health. One further "element" that may be considered within the elemental paradigm is the philosophical consideration of a fifth element, which has been termed as "void," "space," or "ether." This element is generally not present in the Hippocratic-Western framework, yet it is found in other traditional systems such as Ayurveda. In the same Finnish cohort discussed above, there was found to be a strong association between frequent sauna bathing and a reduction of psychotic disorders after a median follow-up of 25 years (51), but this is the only longitudinal evidence currently available.

In respect to clinical considerations for more mainstream lifestyle medicine implementation, recent data from Sweden suggest that there are a range of barriers still persisting (91). Major factors for why lifestyle modifications are not being more commonly implemented in clinical practice include a lack of knowledge and roles, lack of organizational support and resources, a low perceived importance of these measures, and a deficit of time to provide the needed attention. One surprise within these data is that activity was negatively correlated with heart rate in these experimental manipulations across bilateral insula, in association with similar changes throughout the neostriatum. One particular aspect of classic sauna practice that requires further interrogation for general and mental health effects is the common adoption of cold exposure after heat exposure (cold showers/air/snow after the sauna). The classical use of contemporary steam rooms also provides an ambient therapeutic interface with both heat and water.

37) found that cold water immersion after sauna may be safe for patients with chronic heart failure, but that the practice should be conducted with caution (49). The study likewise did not consider qualitative aspects of cold exposure, which has been described as eliciting perceived regeneration in recent ethnographic literature (50). While outside the focus of this review (and in direct contrast to heat based therapies), there is also a recognized potential use of cold therapy alone (cryotherapy) for a range of health applications. 48. Kauppinen K. Sauna, shower, and ice water immersion: physiological responses to brief exposures to heat, cool, and cold. These results suggest that further investigation into cold exposure and sauna bathing is an important area of research, especially considering the prevalence of the practice at a global level. Other studies have suggested a positive effect of mood from a Korean "jjimjilbang" sauna (52, 53), as well as reduction of pain intensity in chronic conditions such as hypertension headaches (54). Given the prevalence of anecdotal reports about the relationship between sauna and improved mental health, this is another promising line of investigation that requires sustained attention from the global scientific community, especially in light of recent positive results concerning the use of whole body hyperthermic (WBH) therapy to alleviate major depressive disorder (55). WBH involves the use of sustained heat for 1-2 h to raise core body temperature (sometimes via a device that heats the inside of a tent that covers the body).

As well as the quality of the air that we breathe, the way that we breathe is also associated with our health and well-being. The quantity and quality of prana and the way it flows through the nadis and chakras determines one’s state of mind. Balneotherapy has also been shown to improve quality of life and symptoms of chronic pain in fibromyalgia patients. Another water-based application is in the use of "surf therapy," which has shown to improve participants’ well-being (65, 66). It is however recognized that this offers a range of other ancillary benefits (beyond direct effects from the immersion in water), including increased mindfulness and atelic skill development, exposure to fresh air and sunlight, and general physical activity. While in-depth exploration of water-based physical activities are outside the auspices of this review, a couple of novel applications of immersive water-based activities are worth noting. Emerging preclinical evidence suggests that air pollution may induce oxidative stress, neuroinflammation, microglial activation, and cerebrovascular dysfunction, while potentially altering the blood-brain barrier (73). For example, a mouse model study investigated whether long-term (10 months) exposure to ambient fine airborne particulate matter compared to filtered air affected depression-related animal behavior and cognitive responses (74). The data revealed that mice exposed to long-term air pollution displayed more depressive-like responses and impairments in spatial learning and memory as compared with mice exposed to filtered air.

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